Presentation is loading. Please wait.

Presentation is loading. Please wait.

Management of Acute Severe Colitis Dr Jayne Eaden Consultant Gastroenterologist, UHCW.

Similar presentations

Presentation on theme: "Management of Acute Severe Colitis Dr Jayne Eaden Consultant Gastroenterologist, UHCW."— Presentation transcript:

1 Management of Acute Severe Colitis Dr Jayne Eaden Consultant Gastroenterologist, UHCW

2 Symptoms Bloody diarrhoea (urgency & tenesmus) Abdominal pain Weight loss Obstructive symptoms Abdominal mass (esp RIF)

3 Warning Signs Fever > 37.8 o C Dehydration –Tachycardia (P>90), Hypotension Abdominal pain and tenderness (beware toxic dilatation and perforation) Patients can look well if been on steroids - beware

4 Other Signs Mouth ulcers Perianal disease Erythema nodosum Pyoderma gangrenosum Eye disease Arthropathy (large joints, asymmetrical and non-deforming)




8 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

9 Differential Diagnoses Bacterial infection –C. diff, Campylobacter, Salmonella, Shigella, E. coli 0157 Viral infection if immuno-compromised (CMV) Amoeba especially if travel history Crohns colitis and ischaemia Diverticulitis can occasionally mimic

10 Investigations on Admission Bloods FBC ESR & CRP U&E, creat LFT (albumin) Blood cultures (if temp > 38°) Glucose (Mg+ and Cholesterol)

11 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

12 Colectomy more likely if: -Mucosal islands present -Dilated small bowel loops

13 Investigations on Admission Arrange a sigmoidoscopy and rectal biopsy. DO NOT prescribe bowel prep –should be done within hours of admission Avoid colonoscopy and barium enema in patients with acute, severe colitis

14 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.

15 Extra Investigations In appropriate patients, send Amoebic Fluorescent Antibody test Check CMV titre if patient is not responding after 3 days (EDTA sample)

16 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.

17 Management Rehydrate with IV fluids Correct electrolyte imbalance (in particular potassium) Nutrition : Low residue diet (IV fluids if vomiting) Inform colorectal surgeons & IBD nurse

18 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

19 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

20 Travis Criteria After three days of intravenous hydrocortisone, the presence of either Stool frequency > 8 times per 24 hours or Stool frequency > 3 times + CRP > 45 gives an 85% likelihood of requiring colectomy on the same admission

21 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

22 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

23 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

24 What dose? 2mg/kg as IV infusion in 500mls glucose over 2-6 hrs Monitor levels ( mcg/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


26 Acute severe UC: the role of cyclosporine – long term outcome Clinical experience from Oxford –76 pts from 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


28 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









37 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

38 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




42 Infliximab for chronic active UC: can we predict who will respond? Serum albumin <30g/l: 67% vs 23% colectomy OR 6.86 ( ) p=0.05 (Lees et al APT 2007) No effect of smoking status, age, stool frequency or disease extent

43 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

44 Management of acute severe UC: a multi disciplinary model Physicians Surgeons Radiologists Pathologists Nurses Dieticians Pharmacists Combined approach The Patient

Download ppt "Management of Acute Severe Colitis Dr Jayne Eaden Consultant Gastroenterologist, UHCW."

Similar presentations

Ads by Google