Ulcerative colitis

Essentials of diagnosis:

•Bloody diarrhea•Lower abdominal cramps & fecal urgency•Anemia, low serum albumin•Negative stool cultures•Sigmoidoscopy is the key to diagnosis

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

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

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

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

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

Distal colitis:

-Early/ frequent relapse:-Maintenance- mesalamine supposositories

(500mg/d) -Oral 5-ASA agents

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

Severe colitis:

General:

•Discontinue oral intake for 24-48hrs.

•Total parenteral nutrition

•Correct acid-base deficits,anemia

•Treat C difficle infection if present.

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

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.

Refractory disease:

•Mercaptopurine•Azathioprine•Transdermal nicotine•Infliximab