MANAGEMENT OF MILD-MODERATE DISTAL COLITIS

Patients with mild to moderate distal colitis may be treated with either oral aminosalicylates, topical mesalamine, or topical steroids. In patients refractory to oral aminosalicylates or topical corticosteroids, mesalamine enemas may still be effective. The unusual patient who is refractory to all of the above agents in maximal doses may require treatment with oral prednisone in doses up to 40-60 mg/day.

The therapeutic plan here is largely determined by the patient’s preference because either oral or topical therapy is effective. Oral therapy with aminosalicylates, either sulfasalazine, olsalazine, or mesalamine, is beneficial in achieving and maintaining remission [1] [9] [10] . Effective doses of sulfasalazine range between 4 and 6 g/day in four divided doses [11] [12] ; for mesalamine, at least 2-4 g/day in divided doses [13] [14] , and for olsalazine 1.5-3 g/day in divided doses [15] [16] [17] [18] , although efficacy of olsalazine in active UC is not conclusively established, perhaps in part because of a confounding dose-related diarrhea. These drugs generally are efficacious within 2-4 weeks [11] [12] [13] [14] [15] [16] [17] [18] and are effective in 40-80% of patients. Intolerance to the sulfapyridine moiety is not uncommon and may result in nausea, vomiting, dyspepsia, anorexia, and headache. More severe, but less common, adverse effects include allergic reactions, pancreatitis, hepatotoxicity, drug-induced connective tissue disease, bone marrow suppression, interstitial nephritis, nephrotoxicity, hemolytic anemia, or megaloblastic anemia. Abnormal sperm counts, motility, and morphology are related to the sulfapyridine moiety and are not seen with the mesalamine preparations. Approximately 80% of patients intolerant to sulfasalazine are able to tolerate olsalazine and mesalamine [9] [18] [19] [20] . However, several of the allergic reactions previously thought to be due to the sulfa moiety have been seen with newer aminosalicylates as well [9] .

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APPROACH TO MANAGEMENT

Goals of treatment are directed at inducing and then maintaining remission of symptoms and mucosal inflammation. Once the diagnosis of UC is confirmed, the anatomic extent is assessed endoscopically. The key question to be addressed at this point is whether the inflammation is “distal” (i.e., limited to below the splenic flexure and thus within reach of topical therapy) or “extensive” (i.e., extending proximal to the splenic flexure, requiring systemic medication). Therefore, a delineation of the proximal margin of inflammation, if not achieved on initial evaluation, is desirable at some point in the management of the case once the patient’s condition permits. Read the rest of this entry »

RECOMMENDATIONS FOR DIAGNOSIS AND ASSESSMENT

In a patient presenting with persistent bloody diarrhea, rectal urgency, or tenesmus, stool examinations and sigmoidoscopy and biopsy should be performed to confirm the presence of a colitis and to rule out infectious causes. Characteristic endoscopic and histologic findings with negative evaluation for infectious causes will suggest the diagnosis of ulcerative colitis.

The diagnosis of UC is suspected on clinical grounds and supported by the appropriate findings on proctosigmoidoscopy or colonoscopy, biopsy, and by negative stool examination for infectious causes. Infectious etiologies of colitis can produce clinical findings indistinguishable from idiopathic UC, so microbiologic studies for bacterial and parasitic infection, as well as serologic testing for ameoba when clinical suspicion is high, should be performed in each new patient and in patients with stable symptoms who develop a severe exacerbation. Similarly, patients who have had recent antibiotics, or have recently been hospitalized, should have stools examined for Clostridium difficile.

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Ulcerative Colitis Practice Guidelines in Adults

INTRODUCTION

Ulcerative colitis (UC) is a disorder characterized by diffuse mucosal inflammation limited to the colon. UC is usually a chronic disease which involves the rectum and may extend proximally in a symmetrical, circumferential, and uninterrupted pattern to involve parts or all of the large intestine. The hallmark clinical symptom is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus (painful straining at stool). The clinical course is marked by exacerbations and remissions, which may occur spontaneously or in response to treatment changes or intercurrent illnesses [1] [2]. Ulcerative colitis affects approximately 250,000 individuals in the United States with an incidence of 2-6 per 100,000 people per year; the prevalence has remained relatively constant over the last five decades.