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Ulcerative colitis
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Essentials of diagnosis:
•Bloody diarrhea•Lower abdominal cramps & fecal urgency•Anemia, low serum albumin•Negative stool cultures•Sigmoidoscopy is the key to diagnosis
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Mild Moderate Severe
Stool frequency/day
<4 4-6 >6(mostly bloody)
Pulse rate <90 90-100 >100
Hematocrit% Normal 30-40 <30
Weight loss% None 1-10 >10
Temperature(0F) Normal 99-100 >100
ESR (mm/hr) <20 20-30 >30
Albumin (g/dL) Normal 3-3.5 <3
Ulcerative colitis: Assessment of disease severity
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5-ASA derivatives in ulcerative colitis: site of absorptionof major drugs
Stomach Jejunum Ileum Colon
Sulfasalazine Olsalazine
Meslamine pH sensitive Release Tablets
Mesalamine Delayed Release Capsules
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Treatment of ulcerative colitis:
Proctitis:•Mesalamine suppositories, 500mg twice daily, or•Hydrocortisone foam, 90mg per rectum daily or•Hydrocortisone suppositories, 100mg per rectum daily
Proctosigmoiditis:•Meslamine enema, 4g per rectum daily, or•Hydrocortisone enema, 100mg per rectum daily
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Treatment of ulcerative colitis:
Extensive colitis:Mild to moderate:•Sulfasalazine, 1.5-3g orally twice daily., or•Mesalamine tablets (delayed release), 2.4-4.8g/day, or•Balsalszide,2.25g three times a day•If no response after 2-4 weeks, add prednisone,20-40mg/d (taper by 5mg/week)
Severe:Methylprednisolone, 48-60mg IV daily
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Distal colitis:
Drug of choice meslamine suppositoryIf patients fail to respond:
-Increase the same topical agent twice daily
-Combination treatment with a 5-ASA enema at bed-time and a corticosteroid enema or foam in the morning.
-Combination of a topical agent with oral 5-ASA agent
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Distal colitis:
-Early/ frequent relapse:-Maintenance- mesalamine supposositories
(500mg/d) -Oral 5-ASA agents
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Mild to moderate colitis:5-ASA derivatives1) Sulfasalazine 500mg bd (along with folic acid
1mg/d)2) Mesalamine 1g four times daily3) Balsalazide 2.25g tid4) Olsalazine 500mg bd
No improvement after 2-3 weeks:Topical steroids5-ASA enemasOral steroids
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Severe colitis:
General:
•Discontinue oral intake for 24-48hrs.
•Total parenteral nutrition
•Correct acid-base deficits,anemia
•Treat C difficle infection if present.
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Severe colitis:Steroids: •Methylprednisolone 48-64mg or hydrocortisone
300mg in 4 divided doses or continuous infusion•Can try ACTH infusion 120 units/24hr.•Cyclosporine IV 2-4mg/kg/d infusion
SURGICAL
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Fulminant colitis and toxic megacolon:
•Broad spectrum antibiotics to cover anaerobes & Gram –ve bacteria•Surgery to prevent perforation
Maintanence of remission:Chronic sulfasalazine, olsalazine, mesalamine.
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Refractory disease:
•Mercaptopurine•Azathioprine•Transdermal nicotine•Infliximab