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G22 Gastroenterology
Small and Large Bowel Toronto Notes 2019
In UC, non-bloody diarrhea is frequently the initial presentation; eventually progressing to bloody diarrhea
Medical Management of Ulcerative Colitis
Induction of Maintenance Remission
5-ASA + + Steroids + Immunosuppressive ± +
Pathology
• diseasecaninvolveanyportionoflowerbowelrangingfromrectumonly(proctitis)toentirecolon (pancolitis)
• inflammationisdiffuse,continuousandconfinedtomucosa
Clinical Features
• rectalbleedingisthehallmarkfeature;diarrheapresentifmorethantherectumisinvolved ■ can also have abdominal cramps/pain, especially with defecation
• severityofcolonicinflammationcorrelateswithsymptoms(stoolvolume,amountofbloodinstool) • tenesmus, urgency, incontinence
• systemicsymptoms:fever,anorexia,weightloss,fatigueinseverecases
• extra-intestinalmanifestations(seeTable11,G20)
• characteristicexacerbationsandremissions;5%ofcasesarefulminant
Investigations
• sigmoidoscopywithmucosalbiopsy(toexcludeself-limitedcolitis)withoutbowelprepoftensufficient for diagnosis
• colonoscopyhelpfultodetermineextentofdisease;contraindicatedinsevereexacerbation
• CTcolonography(formerlybariumenema)ifcolonoscopycannotbedone;contraindicatedinsevere
disease
• stoolculture,microscopy,C.difficiletoxinassaynecessarytoexcludeinfection
• nosingleconfirmatorytest
Treatment
• mainstaysoftreatment:5-ASA(mesalamine)derivatives(onlyinmildtomoderatedisease)and corticosteroids, with azathioprine used in steroid-dependent or resistant cases
• dietoflittlevalueindecreasinginflammationbutmayalleviatesymptoms • anti-diarrhealmedicationsgenerallynotindicatedinUC
■ 5-ASA
◆ topical (suppository or enema): effective for distal disease (rectum to splenic flexure) if
inflammation is mild, preferable to corticosteroids
◆ oral: effective for mild to moderate, but not severe colitis (e.g. sulfasalazine 3-4 g/d, mesalamine
4 g/d)
◆ commonly used in maintaining remission (decreases yearly relapse rate from 60% to 15%) ◆ may decrease rate of colorectal cancer
• corticosteroids
■ to remit acute disease, especially if severe or first attack; may need maximum dose IV steroids
initially (e.g. methylprednisolone 30 mg IV q12h)
■ limited role as maintenance therapy for mild to moderate disease
■ use suppositories (predominantly available in compound pharmacies) for proctitis
■ use enemas and topical steroids (e.g. hydrocortisone foam, budesonide enemas) for inflammation
distal to splenic flexure
• immunosuppressants(steroid-sparing)
■ inhospitalizedpatientswithsevereUC–addIVinfliximabifnoresponsetoIVmethylprednisolone within 3 d; then consider colectomy if inadequate response
■ biologics (infliximab, adalimumab, golimumab, vedolizumab) can also be used for outpatients with moderate-severe disease, particularly those that are steroid-unresponsive or steroid-dependent
■ azathioprine and 6-mercaptopurine: too slow to rapidly resolve acute relapse
◆ most commonly used to maintain remission as corticosteroids withdrawn
◆ given with biologics: increase efficacy of biologics and decrease likelihood of tolerance to
biologics (~ 10% chance/yr) • surgical treatment curative
■ aim for cure with colectomy; bowel continuity can be restored with ileal pouch-anal anastamosis (IPAA)
■ indications: failure of adequate medical therapy, toxic megacolon, uncontrollable bleeding, pre- cancerous changes detected either by endoscopy or endoscopic biopsies (dysplasia), inability to taper corticosteroids, overt malignancy
Complications
• similartoCD,except:
■ more liver problems (especially PSC in men) ■ greaterriskofcolorectalcancer
◆ risk increases with duration and extent of disease (5% at 10 yr, 15% at 20 yr for pancolitis; overall relative risk is 8%)
◆ risk also increases with active mucosal inflammation and sclerosing cholangitis
◆ thus, regular colonoscopy and biopsy in pancolitis of ≥8 yr is indicated
■ toxic megacolon (transverse colon diameter >6 cm on abdominal x-ray) with immediate danger of
When Considering Complications of IBD, Think:
ULCERATIVE COLITIS
Urinary calculi
Liver problems
Cholelithiasis
Epithelial problems
Retardation of growth/sexual maturation Arthralgias
Thrombophlebitis Iatrogenic complications Vitamin deficiencies Eyes
Colorectal cancer Obstruction Leakage(perforation) Iron deficiency
Toxic megacolon Inanition (wasting) Strictures
perforation (see General Surgery, GS37)