Management of Acute Severe Colitis

Dr Jayne Eaden

Consultant Gastroenterologist, UHCW

Symptoms

• Bloody diarrhoea (urgency & tenesmus)

• Abdominal pain

• Weight loss

• Obstructive symptoms

• Abdominal mass (esp RIF)

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

Other Signs

• Mouth ulcers

• Perianal disease

• Erythema nodosum

• Pyoderma gangrenosum

• Eye disease

• Arthropathy (large joints, asymmetrical and non-deforming)

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

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

Investigations on Admission

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

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

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

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

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.

Extra Investigations

• In appropriate patients, send Amoebic Fluorescent Antibody test

• Check CMV titre if patient is not responding after 3 days (EDTA sample)

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.

Management

• Rehydrate with IV fluids

• Correct electrolyte imbalance (in particular potassium)

• Nutrition : Low residue diet (IV fluids if vomiting)

• Inform colorectal surgeons & IBD nurse

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

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

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

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

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

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

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

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

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

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

• 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

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

• 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

Management of acute severe UC:a multi disciplinary model

Physicians Surgeons

RadiologistsPathologists

NursesDieticiansPharmacists

Combined approachThePatient