Ulcerative Colitis


Crohn's VS Ulcerative Colitis
  Crohn's Ulcerative Colitis
Genetic predisposition NOD2. CARD I5, ATG 16L1, IL23R. Presumed genetic component
Worse with smoking Yes Possible improvement
Age at onset Bimodal: 15-25, 55-65 yr Bimodal: 20-40, 60-70 yr
Abdominal pain Sharp, focal Crampy; associated w/ bowel movement
Bowel obstruction Common Rare
Gross hematochezia Occasionally Common
Gl involvement Mouth to anus; typically terminal ileum/proximal colon. Colon only; rectum with continuous progression proximally
Pattern Segmental, transmural eccentric. Continuous, mucosal, circumferential
Ulceration Superficial to deep, linear, selpiginous. Superficial
Histology Non-caseating granulomas. Crypt Abscesses
p-ANCA (+) 20% 70%
ASCA (+) 65% 15%
Fistula/stricture Common. Uncommon
Extraintestinal manifestations uncommon. Common
lnfliximab response Often Occasionally
Colon CA risk Yes INCREASED
Surgery curative Never Often

Background

Etiology (theories)

Pathophysiology

Diagnosis

Complication

Physical examination

Differential Diagnosis

  1. Crohn's disease
  2. C. difficile colitis
  3. Collagenous colitis and lymphocytic colitis
  4. Infectious colitis
  5. Ischemic colitis (elderly pts)
  6. Radiation colitis
  7. Immunocompromised

Classification by presentation (Bloody diarrhea is hallmark)

Treatment

  1. Medical management
  2. Management: Approach
    1. Mild to moderate distal colitis
      • When remission occurs with any step, transition to maintenance dosing of current agent
      • Step 1: Topical 5-ASA at active dose per Rectum for 4-6 weeks
        1. Suppository for isolated Proctitis
        2. Enema for more proximal, left-sided Ulcerative Colitis
      • Step 2: ADD oral 5-ASA at active dose for 4-6 weeks (while continuing rectal 5-ASA)
      • Step 3: Go to step 2 under mild-moderate extensive colitis
    2. Mild to moderate extensive colitis
      • Step 1: Oral 5-ASA at active dose for 4-6 weeks
        1. If remission occurs, continue oral 5-ASA at maintenance dosing
      • Step 2: Oral Corticosteroids for 4-6 weeks
        1. If remission occurs, transition to Azathioprine (Imuran) at maintenance dosing
      • Step 3: Infliximab (Remicade) for 4-6 weeks
        1. If remission occurs, continue Infliximab at maintenance dosing
      • Step 4: Consider third-line medications
        1. Intravenous Corticosteroids
        2. Cyclosporine (Sandimmune)
      • Step 5: Consider surgical intervention
        1. See Surgery below
    3. Severe to fulminant colitis
      • Hospital admission
      • Step 1: Corticosteroids IV at active dose for 3-5 days
        1. If remission occurs, transition to Azathioprine (Imuran) at maintenance dosing
      • Step 2: Consider third-line medications
        1. Cyclosporine (Sandimmune) for 3-5 days
          1. If remission occurs, transition to Azathioprine (Imuran) at maintenance dosing
        2. Infliximab (Remicade) for 3-5 days
          1. If remission occurs, continue Infliximab at maintenance dosing
      • Step 3: Consider surgical intervention
        1. See Surgery below
           
  3. Acute Exacerbation
    Treatment Comments
    Restore fluid and electrolyte balance Identify and treat GI hemorrhage.
    Nothing by mouth
    Nasogastric suction (If needed) For obstruction, adynamic ileus, suspected toxic megacolon.
    Parenteral narcotics Adequate pain control.
    Antibiotics Ciprofloxacin 500 mg BID x 14d
    and 
    Metronidazole 500 mg q6h
    Steroids Prednisone 40-60 mg PO qD (or divided doses) x4-6 wks
    Diagnose complications CT Abd/Pelv to look for Obstruction

     

  4. Mild - Moderate disease
  5. Severe disease (active)
  6. Surgical management

Prognosis

Prevention

Disposition

  1. Severe/Fulminant disease
  2. Disease flare-up

Admit Orders: Ulcerative Colitis

1. Admit to:

2. Diagnosis: Ulcerative colitis

3. Condition:

4. Vital Signs: q4-6h. Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C.

5. Activity: Up ad lib.

6. Nursing: Inputs and outputs.

7. Diet: NPO except for ice chips for 48h, then low residue diet, no milk products.

8. IV Fluids: 1-2 L NS over 1-2h, then D5 ½ NS with 40 mEq KCL/L at 125 cc/hr.
 

9. Special Medications:

-Mesalamine (Asacol) 400-800 mg PO tid
OR

-5-aminosalicylate (Mesalamine) 400-800 mg PO tid or 1 gm PO qid or enema 4 gm/60 mL PR qhs 
OR

-Sulfasalazine (Azulfidine) 0.5-1 gm PO bid, increase over 10 days as tolerated to 0.5-1.0 gm PO qid 
OR

-Olsalazine (Dipentum) 500 mg PO bid

-Hydrocortisone retention enema, 100 mg in 120 mL saline bid.

OR

-Methylprednisolone (Solu-Medrol) 10-20 mg IV q6h 
OR

-Hydrocortisone 100 mg IV q6h 
OR

-Prednisone 40-60 mg PO qd.
 

-B12, 100 mcg IM for 5d then 100-200 mcg IM q month.

-Multivitamin PO qAM or 1 ampule IV qAM.

-Folate 1 mg PO qd.
 

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 325-650 mg PO q6h prn fever.
 

11. Extras: Upright abdomen. CXR, colonoscopy, GI consult.
 

12. Labs: CBC, CMP, liver panel, blood C&S x 2; stool Wright's stain, stool for ova and parasites x 3, culture for enteric pathogens. UA