Ulcerative colitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Mugilan Poongkunran M.B.B.S [2]

To go to ulcerative colitis home page, click here.

## Overview

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Ulcerative colitis (UC) is a chronic disease characterized by recurrent episodes of diffuse inflammation limited to the mucosal layer of the colon and presenting commonly as bloody diarrhea with rectal urgency and tenesmus. It commonly involves the rectum and may extend proximally in a symmetrical, circumferential, and uninterrupted pattern to involve parts of or even the entire large intestine.

## Causes

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### Life Threatening Causes

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Ulcerative colitis (UC) can be a life-threatening condition and must be treated as such irrespective of the underlying cause.

### Common Triggers

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Common factors recognized to exacerbate UC are:

* Campylobacter
* Clostridium difficile infection
* NSAIDS
* Salmonella
* Shigella

## Management

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### Initial Approach

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The algorithm is based on the American College of Gastroenterology guidelines for management of Ulcerative colitis (UC) in adults.[1]

Characterize the symptoms:

* * *

❑ Diarrhea (onset, duration, pattern, frequency, type)
❑ Bowel urgency, tenesmus, and incontinence
❑ Abdominal pain
❑ Rectal bleeding
❑ Constipation
❑ Fever
❑ Fatigue
❑ Nausea
❑ Vomiting
❑ Abdominal distention
❑ Loss of appetite
❑ Loss of weight
❑ Mental status change

* * *

Inquire about extraintestinal symptoms:

* * *

❑ Skin lesions
❑ Joint pains
❑ Cough, breathlessness
❑ Eyes (burning, itching, or redness)

* * *

Obtain a detailed history:

* * *

❑ Recent travel
❑ Recent antibiotic, or NSAID, or isotretinoin use
❑ Abdominal or pelvic radiation
❑ Family history
❑ Systemic illness

❑ Personal history: Smoking

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Assess volume status:

* * *

❑ General condition
❑ Thirst
❑ Pulse
❑ Blood pressure
❑ Eyes
❑ Mucosa

* * *

Examine the patient:

* * *

❑ Skin (swelling, pain, erythema or ulceration)
❑ Abdomen (mass, distension or tenderness)
❑ Respiratory system (wheeze or crackles)
❑ Cardiovascular system
❑ Anorectal (bleeding)
❑ Eyes (swelling, pain, edema or vision loss)
❑ Musculoskeletal (axial, large and small joints)

Order tests:

❑ Complete blood count (CBC)
❑ Erythrocyte sedimentation rate (ESR)
❑ C-reactive protein (CRP)
❑ Serum electrolytes
❑ Total serum protein and albumin
❑ Stool analysis (occult blood, WBC's, calprotectin, culture, ova and parasites)
❑ Stool for Clostridium difficile toxin in case of recent hospitalization or antibiotic use
❑ Urinalysis
❑ BUN
❑ Creatinine
❑ Serum glucose
❑ Liver function tests
❑ Serologic testing for amoeba
❑ STD's: VDRL, PCR (HSV), gonococcal culture

Order confirmatory diagnostic tests:
❑ Colonoscopy and biopsy
❑ Proctosigmoidoscopy and biopsy
❑ Ileocolonoscopy
❑ Computed tomography (CT)
❑ Barium enema
❑ Magnetic resonance imaging

Confirm the diagnosis of UC:

* * *

❑ Findings on proctosigmoidoscopy or colonoscopy

❑ Symmetric, continuous, and circumferential lesions

❑ Rectum involvement (95%)

❑ Findings on histopathology

❑ Mucosal inflammation, noncaseating granuloma, villous atrophy, crypt abscess

❑ Backwash ileitis

❑ Negative stool examination for infectious causes

| ❑ Assess the severity|

Mild

* * *

❑ < 4 loose stools per day (+/- blood)
❑ No dehydration
❑ Mild crampy pain
❑ No fever
❑ Normal hemoglobin
❑ Normal ESR

Moderate

* * *

❑ > 4 loose stools per day (+/- blood)
❑ Mild dehydration
❑ Abdominal pain that is not severe
❑ Low grade fever
❑ Mild anemia not requiring blood transfusions

Severe

* * *

❑ ≥6 loose bloody stools per day
❑ Moderate to severe dehydration
❑ Severe abdominal cramps
❑ High fever (temperature ≥37.5ºC)
❑ HR ≥90 beats/minute
❑ Hemoglobin <10.5 g/dL
❑ Elevated ESR (≥30 mm/hour)
❑ Rapid weight loss

Fulminant

* * *

❑ > 10 loose stools per day
❑ Continuous bleeding
❑ Severe dehydration
❑ Severe abdominal pain
❑ Abdominal distension
❑ High fever (temperature ≥37.5ºC)
❑ HR ≥90 beats/minute
❑ Hemoglobin <10.5 g/dL
❑ Elevated ESR (≥30 mm/hour)
❑ Rapid weight loss

### Management of Mild to Moderate Ulcerative Colitis

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Mild-moderate ulcerative colitis

* * *

❑ Outpatient therapy
❑ Oral rehydration therapy as per stool loss or frequency
❑ Symptomatic therapy:

* Anti-motility agents: Loperamide

* Anticholinergic agents: Propantheline, dicyclomine, or hyoscyamine

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| Distal colitis|

| Extensive colitis|

| Distal 5-8 cm of the rectum (Proctitis)|

| Greater than 8 cm of distal rectum (Proctosigmoiditis)|

Topical (rectal) 5-aminosalicylic acid (5-ASA)

* * *

❑ Mesalamine suppositories: 500 mg BID or 1 g OD

* * *

* * *

Consider topical (rectal) steroids

* * *

❑ Hydrocortisone suppository: 30 mg BID

Topical (rectal) 5-aminosalicylic acid (5-ASA)

* * *

❑ Mesalamine enemas: 1-4 g BID
PLUS
❑ Mesalamine suppositories: 500 mg BID or 1 g OD

* * *

* * *

Consider topical (rectal) steroids

* * *

❑ Hydrocortisone enema/foam: 100 mg BID
PLUS
❑ Hydrocortisone suppository: 30 mg BID

Combination of oral and topical therapy

* * *

❑ Oral sulfasalazine: Titrated up to 4-6 g/day

❑ Oral nonsulfonamide 5-ASA: At least 2 g/day, titrating up to 4.8 g/day of the active 5-ASA moiety

* * *

PLUS

* * *

❑ 5-ASA enemas (1-4 g) and 5-ASA suppositories (500 mg): BID

❑ Steroid foam (100 mg) and/or suppositories (30 mg): BID

* * *

❑ Symptoms so troubling, start with oral steroid therapy

| Response to Rx in 4-6 wks|

| Response to Rx in 4-6 wks|

| Response to Rx in 2-4 wks|

| Yes|

| No|

| No|

| Yes|

| No|

| Yes|

Maintenance therapy

* * *

❑ ONLY Rx patients with > 1 relapse a year
❑ Mesalamine suppositories: 500 mg BID or OD

Combination of oral 5-ASA and topical 5-ASA

* * *

❑ Oral sulfasalazine: 4-6 g/day in four divided doses

❑ Oral mesalamine: 2-4.8 g/day in three divided doses

❑ Oral balsalazide: 6.75 g/day in three divided doses

❑ Oral olsalazine: 1.5-3 g/day in two divided doses

* * *

❑Start at the lower dose and increase to the maximum tolerated dose

* * *

* * *

Combination of topical 5-ASA and topical steroids

* * *

❑ Same dosage

Combination of oral 5-ASA and topical 5-ASA

* * *

❑ Start from a higher dose

* * *

* * *

Combination of topical 5-ASA and topical steroids

* * *

❑ Same dosage

Maintenance therapy

* * *

❑ Rx all patients after the 1st episode
❑ Mesalamine enemas: 2-4 g/day at bedtime

Oral glucocorticoids

* * *

❑ Oral prednisolone: 40-60 mg one or in two divided doses

Maintenance therapy

* * *

❑ Oral sulfasalazine: 4-6 g/day in four divided doses

* * *

PLUS

* * *

❑ Mesalamine suppositories: 1 g/day at bedtime

❑ Mesalamine enemas: 2-4 g/day at bedtime

On remission for 2 years without any relapses|

| Multiple relapses on maintenance therapy|

| Response to Rx in 2-4 wks|

| Multiple relapses on maintenance therapy|

| On remission for 2 years without any relapses|

| Response to Rx in 2-4 wks|

Discontinue maintenance therapy|

| Rx with oral 5-ASA for remission and maintenance|

| Rx with oral 5-ASA for remission and maintenance|

| Discontinue maintenance therapy|

| No|

| Yes|

| Yes|

| No|

Maintenance therapy

* * *

❑ Oral sulfasalazine: 2 g/day

❑ Eudragit-S-coated mesalamine: 3.2 g/day

❑ Extended release mesalamine capsules: 1.5 g/day in four divided doses

❑ Oral balsalazide: 3-6 g/day in three divided doses

❑ Oral olsalazine: 1 g/day in two divided doses

❑ Combination therapy: Oral mesalamine 1.6 g/day and enema 4g biweekly

Rx as extensive colitis

* * *

❑ Oral glucocorticoids

❑ IV infliximab

Intravenous steroids

* * *

❑ Inpatient therapy
❑ IV prednisolone: 30 mg/12 hrs

❑ IV methylprednisolone: 16-20 mg/8 hrs

❑ IV hydrocortisone: 100 mg/8 hrs

| ❑ Taper dose by 5-10 mg/wk over 8 wks until it is 20 mg/day
❑ Then taper dose by 2.5 mg/week and stop|

| Response to Rx in 7-10 days|

| No|

| Yes|

Failure of maintenance therapy

* * *

❑ 6-mercaptopurine (6-MP): 1.5 mg/kg

❑ Azathioprine: 2-2.5 mg/kg

❑ IV infliximab: 5 mg/kg at 0, 2, and 6 wks

Steroid resistant UC therapy

* * *

❑ Azathioprine: 1.5-2.5 mg/kg/day

❑ 6-mercaptopurine (6-MP): 1.5 mg/kg/day

| Switch to oral prednisone (40-60 mg) and start tapering its dose as mentioned above|

| Response to Rx|

| Relapse on tapering|

| Yes|

| No|

| Yes|

| No|

Maintenance therapy

* * *

❑ 6-mercaptopurine (6-MP): 1.5 mg/kg

❑ Azathioprine:2-2.5 mg/kg

❑ IV infliximab: 5-10 mg/kg at 0, 2, and 6 wks

Steroid dependent UC therapy

* * *

❑ IV infliximab: 5-10 mg/kg at 0, 2, and 6 week and thereafter every 8 weeks

❑ SC adalimumab: 160 mg at week 0, 80 mg at week 2, and then 40 mg every 2 weeks

Maintenance therapy

* * *

❑ Oral sulfasalazine: 4-6 g/day in four divided doses

* * *

PLUS

* * *

❑ Mesalamine suppositories: 1 g/day at bedtime

❑ Mesalamine enemas: 2-4 g/day at bedtime

Failure of treatment

* * *

❑ Surgical consultation for colectomy

Failure of maintenance therapy

* * *

❑ 6-mercaptopurine (6-MP): 1.5 mg/kg

❑ Azathioprine:2-2.5 mg/kg

❑ IV infliximab: 5-10 mg/kg at 0, 2, and 6 wks

### Management of Severe and Fulminant Ulcerative Colitis

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Severe colitis

* * *

❑ Outpatient/ Inpatient treatment as per symptom severity
❑ Oral rehydration therapy/ intravenous fluids
❑ Avoid complete colonoscopy
❑ Avoid anticholinergic, antidiarrheal agents, NSAIDs, and opioid drugs

Fulminant colitis

* * *

❑ Inpatient therapy
❑ NPO
❑ Intravenous fluids
❑ Avoid complete colonoscopy
❑ Total parental nutrition
❑ Blood transfusions to have hemoglobin ≥10 g/dL
❑ Monitor vitals every 4-6 hours
❑ Record the stool output
❑ Avoid anticholinergic, antidiarrheal agents, NSAIDs, and opioid drugs

Oral glucocorticoids

* * *

❑ Oral prednisolone: 40-60 mg one or in two divided doses

* * *

PLUS

* * *

High dose oral 5-aminosalicylic acid

* * *

❑ Oral sulfasalazine: 4-6 g/day

❑ Oral mesalamine:4.8 g/day

❑ Oral balsalazide: 6.75 g/day

* * *

PLUS

* * *

Topical therapy

* * *

❑ 5-ASA or steroid suppository
PLUS
❑ 5-ASA, steroid enema, or foam

| No toxic megacolon|

| Toxic megacolon (Colonic diameter ≥6 cm or cecum >9 cm and systemic toxicity)|

| Response to Rx in 2-4 weeks|

| Yes|

| No|

| ❑ Taper the dose of steroids as mentioned above

❑ Monitor for any relapses and treat accordingly

❑ Start the patient on maintenance therapy as above

Inpatient management

* * *

❑ NPO
❑ Intravenous fluids: Normal saline or ringer lactate

* * *

Intravenous steroids

* * *

❑ IV prednisolone: 30 mg/12 hrs

❑ IV methylprednisolone: 16-20 mg/8 hrs

❑ IV hydrocortisone: 100 mg/8 hrs

* * *

Broad-spectrum antibiotics

* * *

❑ IV ciprofloxacin
PLUS
❑ IV metronidazole:

* * *

Venous thromboembolism prophylaxis

Inpatient management

* * *

❑Nasoenteric tube decompression

❑ Intermittent rolling maneuvers every 2 hrs

❑ Knee-elbow position

* * *

Intravenous steroids

* * *

❑ IV prednisolone: 30 mg/12 hrs

❑ IV methylprednisolone: 16-20 mg/8 hrs

❑ IV hydrocortisone: 100 mg/8 hrs

* * *

Broad-spectrum antibiotics

* * *

❑ IV ciprofloxacin
PLUS
❑ IV metronidazole:

* * *

Venous thromboembolism prophylaxis

* * *

Immediate treatment for hypokalemia or hypomagnesemia

| Response to Rx in 6-8 days|

| Response to Rx in 72 hrs|

| Yes|

| No|

| Yes|

| No|

| ❑ Continue IV steroids till 10th day
❑ Switch to oral steroids and monitor the response
❑ Taper the dose of steroids as mentioned above

❑ Monitor for any relapses and treat accordingly

❑ Start the patient on maintenance therapy as above|

| ❑ Continue IV steroids till 10th day
❑ Switch to oral steroids and monitor the response
❑ Taper the dose of steroids as mentioned above

❑ Monitor for any relapses and treat accordingly

❑ Start the patient on maintenance therapy as above|

| Surgical consultation for colectomy|

Cyclosporine

* * *

❑ IV cyclosporine: 4 mg/kg per 24 hours as continuous infusion

Infliximab

* * *

❑ IV infliximab: 5-10 mg/kg

| Response to Rx within 48-72 hrs|

| Response to Rx in 48-72 hrs|

| Yes|

| No|

| Yes|

Bridging therapy

* * *

❑ Oral cyclosporine: 8 mg/kg/day as microemulsion
❑ Taper off the glucocorticoids over the first 4-6 weeks
❑ Taper off cyclosporine microemulsion over the next 6-8 weeks
❑ Start then 6-mercaptopurine (6-MP) or azathiopriner>

| Surgical consultation for colectomy|

| ❑ IV infliximab: 5-10 mg/kg at 2 and 6 wks and every 8 weeks thereafter|

## Do's

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* Always first assess the volume status and correcting fluid and electrolyte disturbances take priority over the specific treatment in ulcerative colitis patients.
* Do perform a flexible sigmoidoscopy in hospitalized patients with severe colitis and the evaluation should be limited to the rectum and distal sigmoid colon.
* Do prescribe oral 5-ASA medications to patients who are unwilling or unable to tolerate topical medications.
* Do complete blood cell count and liver function tests at the initiation of 5-ASA therapy with subsequent monitoring every two weeks during the first three months, then monthly for the second three months, and every three months thereafter.
* Order serum blood urea nitrogen, creatinine and urinalysis testing at 6 weeks, 6 months, and 12 months after initiation of 5-ASA therapy and then annually.[2]
* Order complete blood counts, initially every 1-2 weeks and at least every 3 months for patients on azathioprine, 6 mercaptopurine and other immunomodulator therapy to avoid the risk of acute or delayed bone marrow suppression.[3]
* Always determine thiopurine methyltransferase (TPMT), the primary enzyme-metabolizing azathioprine/6-mercaptopurine, activity or genotype prior to initiating treatment with azathioprine or 6-mercaptopurine.[3]
* Do monitor cyclosporine blood levels every one to two days after each dose change, and every two to three days when on stable doses.
* Do carefully monitor patients on cyclosporine for electrolyte abnormalities, nephrotoxicity, hypertension, neurotoxicity, and infections. Prophylaxis against Pneumocystis pneumonia (PCP) during therapy is required.
* Do reassess the extent of disease, compliance and consider coexisting conditions, if a patient has a recurrence of symptoms after initial improvement that does not mimic the initial presentation.
* Do recommend intravenous antibiotics (eg, ciprofloxacin and metronidazole) for all UC patients with high grade fever, leukocytosis and peritoneal signs or megacolon.
* Do a repeat stool analysis in patients with steroid-dependent or steroid-refractory ulcerative colitis in order to exclude a superimposed infection.
* Do recommend prophylaxis for venous thromboembolism for hospitalized ulcerative colitis patients.[4]
* Do maintain IBD patients on glucocorticoids for more than 3 months, on calcium (1200 mg/day) and vitamin D (800 IU/day) through either diet and/or supplements.
* Absolute indications for surgery are exsanguinating hemorrhage, perforation, and documented or strongly suspected carcinoma.
* Do review the vaccination status of the patient at the time of diagnosis of UC and if live vaccines are required, they should be administered 4 to 12 weeks prior to the initiation of immunosuppression.
* Colonoscopic surveillance for cancer should begin after eight years in patients with pancolitis, and 15 years in patients with colitis involving the left colon and should be repeated every one to two years. [5][6]

## Dont's

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* Don't treat patients with severe diarrheal dehydration using 5% dextrose with 1/4 normal saline, as using solutions with lower amounts of sodium (such as 38.5 mmol/L in 1/4 saline with 5% dextrose ) would lead to sudden and severe hyponatremia with a high risk of death.[7]
* Oral rehydration therapy is contraindicated in the initial management of severe dehydration, in patients with frequent and persistent vomiting (more than four episodes per hour), and painful oral conditions such as moderate to severe thrush.
* Dont perform a full colonoscopy in hospitalized patients with severe colitis because of the potential to precipitate toxic megacolon.
* Dont use opiods, NSAID's, anticholinergic and antidiarrheal agents in patients with severe colitis because of the potential to precipitate toxic megacolon.
* Dont start maintenance therapy for patients with a first episode of mild ulcerative proctitis that has responded promptly to treatment.
* Dont use oral glucocorticoids for maintenance of remission.
* Dont taper steroids rapidly as it can cause early relapse and also may be associated with adrenal insufficiency.[8]
* Dont continue oral 5-ASA medications if an ulcerative colitis flare coincides with a recent increase in dose or addition of the medication.
* Dont continue immunomodulator therapy in the occurrence of any hypersentivity reactions or any of their toxic side effects.
* Dont use infliximab in patients with active infection, untreated latent tuberculosis (TB), preexisting demyelinating disorder or optic neuritis, moderate to severe congestive heart failure, or current or recent malignancies.

## References

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1. ↑ Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology (2010). "Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee". Am J Gastroenterol. 105 (3): 501–23, quiz 524. doi:10.1038/ajg.2009.727. PMID 20068560.CS1 maint: Multiple names: authors list (link)
2. ↑ Gisbert JP, González-Lama Y, Maté J (2007). "5-Aminosalicylates and renal function in inflammatory bowel disease: a systematic review". Inflamm Bowel Dis. 13 (5): 629–38. doi:10.1002/ibd.20099. PMID 17243140.CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 Lichtenstein GR, Abreu MT, Cohen R, Tremaine W, American Gastroenterological Association (2006). "American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease". Gastroenterology. 130 (3): 940–87. doi:10.1053/j.gastro.2006.01.048. PMID 16530532.CS1 maint: Multiple names: authors list (link)
4. ↑ Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR; et al. (2008). "Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 381S–453S. doi:10.1378/chest.08-0656. PMID 18574271.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ Farraye FA, Odze RD, Eaden J, Itzkowitz SH (2010). "AGA technical review on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease". Gastroenterology. 138 (2): 746–74, 774.e1–4, quiz e12-3. doi:10.1053/j.gastro.2009.12.035. PMID 20141809.CS1 maint: Multiple names: authors list (link)
6. ↑ Farraye FA, Odze RD, Eaden J, Itzkowitz SH, McCabe RP, Dassopoulos T; et al. (2010). "AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease". Gastroenterology. 138 (2): 738–45. doi:10.1053/j.gastro.2009.12.037. PMID 20141808.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
7. ↑ "http://www.worldgastroenterology.org/assets/export/userfiles/Acute Diarrhea_long_FINAL_120604.pdf" (PDF). Retrieved 2 January 2014. External link in `|title=` (help)
8. ↑ Carter MJ, Lobo AJ, Travis SP, IBD Section, British Society of Gastroenterology (2004). "Guidelines for the management of inflammatory bowel disease in adults". Gut. 53 Suppl 5: V1–16. doi:10.1136/gut.2004.043372. PMC 1867788. PMID 15306569.CS1 maint: Multiple names: authors list (link) CS1 maint: PMC format (link)

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