Severe Ulcerative Colitis

United European of Gastroenterology

Ahmed Abdul Ghany

Bloody diarrhea ≥ 6 motions/ day

Pulse ≥ 90 bpm

Body temperature ≥ 37.8 C

Hemoglobin ≤ 10.5 g/dl

ESR ≥ 30 mm/hr

Role of Colonoscopy

Full colonoscopy should NOT be made due to risk of perforation instead flexible endoscopy may be indicated to assess severity.

Management

• Hospital admission for IV fluids and electrolyte replacement.

• DVT and pulmonary embolism prophylaxis

• IV antibiotics ONLY in patients with high grade fever, leukocytosis and megacolon.

• Enteral nutrition is preferred (NPO in fulminant colitis)

Initial therapy

• Methylprednisolone 20 mg IV every 8 hrs for 1 week.

• High dose oral 5-ASA (Pentaza 4.8 gm daily)

• 5-ASA / steroids enemas and suppository

Maintenance therapy

• Patients who respond to IV glucocorticoids should be converted to equivalent dose of oral steroids

• Oral steroids tapered after 2- 4 weeks

• Rectal 5- ASA / Steroids can be tapered over 2 – 4 months

• Oral 5- ASA should be continued at the same dose.

If he patient did not achieve remission (≤ 3motions a day) by day 3 consider using second line therapy: Azathioprine or Infliximab.

COLECTOMY

• For patients having 4- 8 motions with blood and CRP ≥ 45 mg/L or motions ≥ 8 without blood, the likelihood for later colectomy during the same admission was 85%.

• Total colectomy with ileostomy with preservation of the rectum is advised for a later restorative procedure.

SURVEILLANCE