Makindo Medical Notes.com

Treat with high dose steroids for 3 days and then decide if rescue therapy which is Infliximab, Ciclosporin or a Colectomy is needed

About

• Can lead to serious complications most notably Megacolon and bowel perforation.
• Inflamed bowel tries to empty contents.

Clinical

• Fever, malaise, anorexia.
• Frequent bowel motions. Assess if blood or pus or mucus or a mix of all.
• Associated abdominal pain and tenderness
• Is there known IBD and what is extent

Causes

• Inflammatory bowel disease: May have known disease or symptoms over months.
• If so find out details and disease extent if colonoscopy as well as histology
• Pseudomembranous colitis: recent antibiotics
• Infectious: travel. Ask about HIV.
• Consider food poisoning and typhoid

Extent of Ulcerative Colitis

Clinical

• Often toxic, fever, dehydrated, pyrexial, unwell.
• Rectal bleeding, diarrhoea, tenesmus and lower abdominal crampy discomfort.
• Tachycardia increases by 30 on sitting suggest hypovolaemia.
• Postural Hypotension. Is abdomen distended. Peritonism. Guarding.
• Low JVP. Poor capillary return.

Key Questions

• How many bowel movements per day ?
• Is there blood in the stools ?
• Is there a pyrexia ?
• Is the pulse rate > 90 bpm ?
• Is the ESR elevated ?
• Is the Hb low ?

Investigations

• FBC, U&E, LFTs, Mg, Ca, Amylase, Lactate, CRP, Glucose. Consider HIV and TB testing. CMV PCR.
• Stool sample for C Difficile toxins A and B, salmonella, shigella, Campylobacter, E Coli
• Persistent Diarrhoea > 7 days and Immunocompromised Giardia, Cryptosporidium and Isospora belli
• Persisting Diarrhoea and HIV: Test for Microsporidia, Mycobacterium avium intracellulare, CMV
• Erect CXR and Abdominal X-Ray which may need to be repeated daily if not settling
• TPMT levels if considering starting Azathioprine
• QuantiFERON status or PPD if likely to need rescue therapy
• Following suggest Severity

If rescue therapy likely to be needed then get the relevant bloods off early so can be started on Day 4

Differential

• Acute Viral Gastroenteritis: Non-bloody, watery stool, mild disease, afebrile. Supportive treatment. Barrier nursing. Side room. Stool culture and microscopy. Consider Loperamide 2 mg bd to shorten course
• Acute Colitis Due to Bacterial Infection: Barrier nursing. Side room. Stool culture and microscopy. Consider Antibiotics: Ciprofloxacin and Metronidazole can be given IV or orally if infectious suspected
• Acute Severe Colitis Due to Clostridioides difficile: Barrier nursing. Side room. Stool culture and microscopy. Suspected C Difficile: Give Vancomycin 250-500 mg PO QDS until results of testing for C. difficile toxin are available. Monitor closely and watch for Megacolon which may require surgery
• Acute colitis related to NSAIDs

Severity Assessment

Management of Acute Severe Colitis Due to IBD

• The severity of acute ulcerative colitis is usually defined by the original classification put forward by Truelove and Witts and this is key in decision making and helps to direct therapy. A stool frequency of >8 or a C-reactive protein (CRP) > 45 on day 3 of admission predicts an 85% likelihood of requiring a colectomy during that admission. Corticosteroids remain the cornerstone of initial therapy, although a third of patients will not respond. If this is not working by 72 hours then this may be escalated to Rescue therapy. If there is an improvement it may be switched to oral prednisolone (40 mg daily with a taper over the next 2-3 months). There is no role generally for antibiotics unless you suspect C difficile and start before results come back.
• Mild to moderate cases can be managed with oral fluids and oral or IV steroids and close ongoing monitoring to ensure they settle and can be discharged on Prednisolone for outpatient follow up. Note that high dose steroids can mask abdominal symptoms and signs so have a low threshold for repeating the AXR to exclude megacolon or perforation or other changes.
• Those with Severe colitis using the above criteria should have daily review by a Gastroenterologist and on Day 3/4 a Colorectal surgeon. They need IV Fluids and correction of electrolytes especially potassium, magnesium and phosphate. For all, it is important to stop any opiates, anticholinergics, loperamide or other drugs delaying bowel motility. It is usual to transfuse anaemia to keep Hb > 10g/dL. They need VTE prophylaxis as even with some bleeding this is a prothrombotic state and compression stockings and LMWH prophylaxis should be prescribed. It is possible to have acute severe colitis related to ulcerative colitis and Clostridioides difficile at the same time. If this is suspected then oral vancomycin should be given.
• Those with severe disease are started on IV steroids on Day 1 and then the usual plan is to review daily but if by Day 4 after 72 hours of IV steroids that things have not improved then they need to be assessed by a multidisciplinary team including a gastroenterologist and colorectal surgeon for rescue therapy which includes either Infliximab, Ciclosporin or Surgery. It is vital to manage any prerenal AKI and keep an accurate stool chart with frequency and type. The immediate objective is to achieve clinical remission as defined by =3 stools per day without rectal bleeding. These patients may be malnourished from food avoidance and evidence suggests that enteral nutrition is best.
• Those with severe disease can have a limited unprepped flexible sigmoidoscopy when indicated should be performed without bowel preparation by an experienced endoscopist. Minimal air insufflation is used to reduce the risk of perforation especially when there are deep and extensive ulcers. This can help determine the diagnosis and severity of the disease. Infectious causes of colitis will show rectal sparing at sigmoidoscopy. Where indicated biopsies may be taken to exclude CMV if there is any consideration of reduced immunity. If CMV is suspected then needs Ganciclovir. Deep extensive ulcers suggest a high risk of failing steroid therapy. If the inflammation is suspected to be related to Inflammatory Bowel disease then start Hydrocortisone100 mg IV 6 hourly.
• Abdominal X- rays can be useful. The presence of Mucosal islands (or "thumb printing"), is a predictor of failure of medical treatment. The presence of faecal residue is consistent with uninflamed or normal colonic mucosa. Measurement of the transverse colonic and caecal diameter (diameter >5.5 cm) supports the presence of colonic dilatation and impending toxic dilatation. An erect chest radiograph or a lateral decubitus abdominal film may reveal colonic perforation.

Rescue therapy

• Infliximab 5 mg/kg usually for 46 weeks: IFX is a chimeric IgG1 monoclonal antibody that specifically targets free and membrane-bound TNF-a and is now used. Concerns of reactivation of latent TB, opportunistic infections and sepsis. Screen for tuberculosis, and hepatitis and avoidance in the presence of such infection or sepsis. Infliximab 5mg/kg body weight infused intravenously over a 2-hour period followed by additional 5mg/kg infusions at 2 and 6weeks after the first infusion, then every 8 weeks.
• Ciclosporin 2 mg/kg. Check magnesium and cholesterol before Ciclosporin. Low levels increase the risk of nerve damage. Can be converted to Azathioprine. Patients will need PCP prophylaxis.
• Colectomy: All patients should be assessed regularly by a consultant Gastroenterologist and colorectal surgeon and a decision made on rescue therapy and emergency subtotal colectomy. The emphasis is on saving lives and not colons. Delaying or denying colectomy to the patient failing medical treatment may lead to adverse outcomes. Colectomy may still be needed if Infliximab or Ciclosporin therapy is not successful. Patients should see a stoma therapist prior to surgery.
• Patients remain hospitalised focusing on nutrition until severity has resolved and clinical improvement.

References

• Jain S, Ahuja V, Limdi JK Optimal management of acute severe ulcerative colitis Postgraduate Medical Journal 2019;95:32-40.
• Management of acute severe colitis Simon L. Jakobovits, S. P. L. Travis British Medical Bulletin, Volume 75-76, Issue 1, 2005, Pages 131-144
• Infliximab for acute exacerbations of ulcerative colitis Technology appraisal guidance
• Updates in Inflammatory Bowel Disease, Dr. Benjamin L. Cohen discusses the management of patients with acute, severe ulcerative colitis (UC).