Dr John P Wright
Updated: 12 September 2011
One of the nightmares in gastroenterology is the rapidly deteriorating patient with a severe attack of ulcerative colitis. The speed with which a patient can deteriorate can shock both physician and patient. The patient's family can only look on in horror as their loved one fades away with pouring bloody diarrhoea and sepsis.
In this situation every decision is criticaland close observation of the patient essential.
The initial task is to stabilise the patient's clinical condition with intravenous fluids and electrolytes.
The second task is to confirm that the attack is due to ulcerative colitis ? A more common cause of fulminating diarrhoea is an infective colitis. Common infections such as Shigella or Salmonella can also occur in patients with ulcerative colitis. While waiting for a stool culture immediate treatment with ciprofloxacin and metronidazole might be appropriate. An antigen test for Clostridium difficile must all ways be done. Patients with ulcerative colitis may also improve with fluid and antibiotics so regular review of the patient’s progress is essential.
Management of Severe Ulcerative Colitis
Having stabilised the patient the attention turns to the underlying ulcerative colitis. There are two modalities to consider, medical or surgical therapy. Medical therapy uses drugs with varying degrees of toxicity; surgery is total colectomy and ileo-anal pouch creation. The first may settle the patient in hours, or, by delay, increase the risk of surgery. Surgery has its own morbidity and mortality.
In addition the fear of failure may influence the medical decision making. While the patient just wants the disease gone, the doctor is more concerned with the historically high mortality associated with fulminant ulcerative colitis. If on one hand the physician delays,the patient may be too sick for safe surgery to be performed. While on the other hand if the patient has a colectomy neither the physician nor the surgeon will be living with this mutilating but possibly life-saving procedure. In this situation the physician may take the easy way out and go with surgery before exhausting the medical options available.
The Medical Option
Even in 2011 many patients will be treated with high-dose corticosteroids. Fortunately in most patients this will bring the disease under control but relapse is inevitable and toxicity assured. Once the acute symptoms have subsided attention must be turned to maintenance therapy to prevent relapse. First line maintenance therapy will be an immunosuppressant such as azathioprine or methotrexate. This needs to be started urgently and carefully monitored to avoid side-effects.
Rather than toxiccorticosteroidsthe acute drugs of choice are currently cyclosporine or anti-TNF antibodies such as Revellex and Humira. The response rates are still not clear but are about 75, 65 and 50% respectively. Remission rates are about half that of the response rates. In clinical practice it is more difficult to predict the response in an individual patient but all tend act quickly in susceptible patients.
The Surgical Option
A colectomy needs to be performed when medical options have failed to control the disease process. The measurement of this tipping point is difficult and subjective. This is one situation where the patient and his/her family will need the advice of the medical attendants. Urgent colectomy may be life-saving and remove the disease but the symptoms of diarrhoea and incontinence may well continue forever. The decision may be a life changing experience for both doctor and patient.
The complications of emergency colectomy and ileo anal pouch creation include a 20% small bowel obstruction rate, 2% impotence, 10-60% pouchitis. 56 – 98% decrease in female fertility, 4% pouch-vaginal fistula and as indicated above stool frequency of 3–10/24 hours with nocturnal incontinence in many patients. Some patients develop Crohn’s disease in the residual small bowel years after the colectomy.
So, how should these patients be managed? Firstly, a medical gastroenterologist with a surgical colleague needs to manage these patients. Secondly patients with known inflammatory bowel disease need to be actively managed with maintenance therapy to avoid the sudden deterioration discussed above.