management of acute severe colitis dr jayne eaden consultant gastroenterologist, uhcw
TRANSCRIPT
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Management of Acute Severe Colitis
Dr Jayne Eaden
Consultant Gastroenterologist, UHCW
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Symptoms
• Bloody diarrhoea (urgency & tenesmus)
• Abdominal pain
• Weight loss
• Obstructive symptoms
• Abdominal mass (esp RIF)
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Warning Signs
• Fever > 37.8 oC
• Dehydration – Tachycardia (P>90), Hypotension
• Abdominal pain and tenderness (beware toxic dilatation and perforation)
• Patients can look well if been on steroids - beware
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Other Signs
• Mouth ulcers
• Perianal disease
• Erythema nodosum
• Pyoderma gangrenosum
• Eye disease
• Arthropathy (large joints, asymmetrical and non-deforming)
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Truelove & Witts Criteria
Defines severe Ulcerative Colitis
Bowels open > 6 times per 24 hours
Plus any one or more of the systemic manifestations• Haemoglobin < 10.5• ESR > 30• Pulse rate > 90• Temperature > 37.5
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Differential Diagnoses
• Bacterial infection – C. diff, Campylobacter, Salmonella,
Shigella, E. coli 0157
• Viral infection if immuno-compromised (CMV)
• Amoeba especially if travel history• Crohn’s colitis and ischaemia• Diverticulitis can occasionally mimic
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Investigations on Admission
Bloods • FBC• ESR & CRP• U&E, creat• LFT (albumin)• Blood cultures (if temp > 38°)• Glucose • (Mg+ and Cholesterol)
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Investigations on Admission
• Stool Culture and Microscopy • C. Diff (3 separate samples)
• AXR: look for stool-free colon (indicates extent involved); severe disease indicated by mucosal oedema (thickened wall), mucosal islands, dilated small bowel loops, colonic dilatation (diameter > 6cm)
• Inform the surgeons on call if the colon is dilated
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Colectomy more likely if:-Mucosal islands present-Dilated small bowel loops
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Investigations on Admission
• Arrange a sigmoidoscopy and rectal biopsy. DO NOT prescribe bowel prep– should be done within 24 - 48 hours of
admission
• Avoid colonoscopy and barium enema in patients with acute, severe colitis
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Daily Investigations
• Bloods– FBC– U&E, creat (particularly watch the potassium)– LFT– CRP (a vital prognostic guide)
• AXR for severe extensive colitis (any of fever, tachycardia, tenderness, dilatation on initial films) – in absence of these criteria less frequent AXR is OK
• Results must be reviewed the same day (esp potassium) particularly if abdominal X-ray is requested.
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Extra Investigations
• In appropriate patients, send Amoebic Fluorescent Antibody test
• Check CMV titre if patient is not responding after 3 days (EDTA sample)
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Daily Monitoring
• Temperature and pulse• Stool chart
– Frequency– Colour / blood content– Estimate of volume (record even if only passed
blood or mucus)• Abdo examination findings
– tenderness, bowel sounds• Note increasing pulse / temp / abdominal pain
or tenderness may indicate deterioration or frank perforation and requires appropriate urgent investigation and d/w SpR / consultant.
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Management
• Rehydrate with IV fluids
• Correct electrolyte imbalance (in particular potassium)
• Nutrition : Low residue diet (IV fluids if vomiting)
• Inform colorectal surgeons & IBD nurse
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Management
• Corticosteroids: Hydrocortisone 100mg QDS IV until remission achieved. May use Predsol/Predfoam PR once or twice per day (mainly for distal disease)
• Antibiotics (if febrile / toxic dilatation)
• Severely anaemic patients (Hb < 9g / dl) should be considered for transfusion
• DVT prophylaxis e.g enoxaparin 40mg od
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Management
• Look for and treat proximal constipation
• If stop 5-ASA, restart on discharge
DO NOT
• Use opiates / codeine phosphate/ loperamide (may precipitate paralytic ileus, megacolon and proximal constipation)
• Use anti-cholinergics
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Travis Criteria
After three days of intravenous hydrocortisone, the presence of
either• Stool frequency > 8 times per 24 hoursor• Stool frequency > 3 times + CRP > 45
gives an 85% likelihood of requiring colectomy on the same admission
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The Management of Acute Severe UC: options for rescue.......
If no improvement by day 3 make plans for day 5!
– Surgery
or– Cyclosporine
or– Infliximab
• MUST be discussed with a Consultant Gastroenterologist
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Indications for colectomy
• Toxic dilatation with failure to improve clinically / radiologically within 24 hrs
• Perforation
• Uncontrolled lower GI haemorrhage
• Failure to respond after 3 days IV steroids
• Deterioration at any stage
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Acute severe UC:the role of cyclosporine
• Only use if stool cultures negative
• Toxic drug – safety is paramount– IV hydrocortisone is continued– Check Mg+ and ensure cholesterol >3– Be aware of side effects (seizures)– Care in elderly / hypertensive / impaired
renal function
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What dose?• 2mg/kg as IV infusion in 500mls glucose over
2-6 hrs• Monitor levels (100-200mcg/l trough)
– Levels monitored at UHCW Mon-Fri
• Rapid steroid wean once clinical response• If responded switch to oral after 3-5 days:
– 5mg/kg/day in 2 divided doses
Acute severe UC:the role of cyclosporine
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Acute severe UC:the role of cyclosporine – long term outcome
• Clinical experience from Oxford
– 76 pts from 1996-2003 followed 2.9 yrs
– 54 received 4mg/kg, 22 oral 5mg/kg
– 74% entered clinical remission and left hospital
– BUT 65% relapse at 1 yr, 90% at 3 yrs
– 58% of those came to colectomy at 7 yrs
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Acute severe UC:the role of cyclosporine – exit strategy
• Azathioprine naive vs refractory........
• Ideally check TPMT levels on admission• Commence Azathioprine at discharge• Wean off Cyclosporine after 6-8 weeks• Septrin 960mg alt days – prophylaxis against
opportunistic infection• Early follow up to check remission and bloods
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Acute severe UC:the role of infliximab – safety issues
• Possible risk of lymphoma & malignancy– Increased if pt on other immunosuppressants
• Infectious complications (VZV, candida)– Serious in 3%
• TB reactivation (PPD & CXR required prior to treatment)
• Interactions tacrolimus / live vaccines
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• Contraindications: – Sepsis – Significantly raised LFTs (x3), – Hypersensitivity to infliximab– Active TB– Pregnancy } avoid for 6 months after – Breast Feeding } stopping treatment
• Cautions: – Previous TB– Hepatic Impairment– Renal Impairment– Heart Failure– Mouse allergies– > 14 weeks since last infusion
Acute severe UC:the role of infliximab – safety issues
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Infliximab for chronic active UC:can we predict who will respond?
• Serum albumin <30g/l: 67% vs 23% colectomy OR 6.86 (1.03-45.6) p=0.05 (Lees et al APT 2007)
• No effect of smoking status, age, stool frequency or disease extent
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• Acute severe UC requires specialist care within an experienced MDT
• Confirm diagnosis and exclude infection
• Non responders should be identified early and salvage therapy considered
• Controlled trials of cyclosporine vs infliximab are awaited
Management of acute severe UC:summary of evidence
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Management of acute severe UC:a multi disciplinary model
Physicians Surgeons
RadiologistsPathologists
NursesDieticiansPharmacists
Combined approachThePatient