Ulcerative colitis

Essentials of diagnosis: Bloody diarrhea Lower abdominal cramps & fecal urgency Anemia, low serum albumin Negative stool cultures Sigmoidoscopy is the key to diagnosis

Ulcerative colitis: Assessment of disease severity Mild Moderate Severe Stool frequency/day <4 4-6 >6(mostly bloody) Pulse rate <90 90-100 >100 Hematocrit% Normal 30-40 <30 Weight loss% None 1-10 >10 Temperature(0F) 99-100 ESR (mm/hr) <20 20-30 >30 Albumin (g/dL) 3-3.5 <3

Stomach Jejunum Ileum Colon         Sulfasalazine Olsalazine Meslamine pH sensitive Release Tablets Mesalamine Delayed Release Capsules 5-ASA derivatives in ulcerative colitis: site of absorption of major drugs

Treatment of ulcerative colitis: Proctitis: Mesalamine suppositories, 500mg twice daily, or Hydrocortisone foam, 90mg per rectum daily or Hydrocortisone suppositories, 100mg per rectum daily Proctosigmoiditis: Meslamine enema, 4g per rectum daily, or Hydrocortisone enema, 100mg per rectum daily

Treatment of ulcerative colitis: Extensive colitis: Mild to moderate: Sulfasalazine, 1.5-3g orally twice daily., or Mesalamine tablets (delayed release), 2.4-4.8g/day, or Balsalszide,2.25g three times a day If no response after 2-4 weeks, add prednisone,20-40mg/d (taper by 5mg/week) Severe: Methylprednisolone, 48-60mg IV daily

Distal colitis: Drug of choice meslamine suppository If patients fail to respond: Increase the same topical agent twice daily Combination treatment with a 5-ASA enema at bed-time and a corticosteroid enema or foam in the morning. Combination of a topical agent with oral 5-ASA agent

Distal colitis: Early/ frequent relapse: Maintenance- mesalamine supposositories (500mg/d) -Oral 5-ASA agents

Mild to moderate colitis: 5-ASA derivatives Sulfasalazine 500mg bd (along with folic acid 1mg/d) Mesalamine 1g four times daily Balsalazide 2.25g tid Olsalazine 500mg bd No improvement after 2-3 weeks: Topical steroids 5-ASA enemas Oral steroids

Severe colitis: General: Discontinue oral intake for 24-48hrs. Total parenteral nutrition Correct acid-base deficits,anemia Treat C difficle infection if present.

Severe colitis: Steroids: Methylprednisolone 48-64mg or hydrocortisone 300mg in 4 divided doses or continuous infusion Can try ACTH infusion 120 units/24hr. Cyclosporine IV 2-4mg/kg/d infusion SURGICAL

Fulminant colitis and toxic megacolon: Broad spectrum antibiotics to cover anaerobes & Gram –ve bacteria Surgery to prevent perforation Maintanence of remission: Chronic sulfasalazine, olsalazine, mesalamine.

Refractory disease: Mercaptopurine Azathioprine Transdermal nicotine Infliximab