Fulminant Colitis New Challenges M62 Coloproctology course 2004

Issues Changing patterns of disease Developments in drug therapy Timing surgical intervention Surgical practice

Patterns of Disease IBD Rising incidence of Crohn’s disease Copenhagen –presentation –investigation

Patterns of Disease IBD Rising incidence of Crohn’s disease Copenhagen – presentation –investigation

Patterns of Disease UCCrohn’s

Patterns of Disease non-IBD Clostridum difficile Vascular disease Immune-compromised

Pseudomembranous colitis Rising incidence %/10yrs Recurrent attacks – 20% Subtotal colectomy – 100% mortality –Pre-op D – 46% Koss 2004 Dallal 2002 Morris 2002 Sharma 2003 Koss 2004 Source Nr Cases Cdiff SevereMort Hosp % Hosp % NOF % Gastro1338%

Pseudomembranous colitis Immunosupression –Lung TT CT diagnosis

Cardiac Patients Major GI complications- high mortality Surgical decisions - complex –Cardiac surgery: scope: stool cultures CentreNrs GI Compl C- diff Isc- aemia Mort Texas11, % Frankf.1, %

Imuno-compromised patients Cytomegalovirus infection –Refractory colitis –30% (16/47) infected –8/12 responded to treatment Wada 2003 Immunosuppressed IBD –23/23 colitis –0/10 CRC –21/23 early a’gen +ve Rahbar 2003 Mimics PMC Olfinlade 2001 Study of CMV/PMC in acute colitis required

Medical Management developments The Oxford criteria –the five day rule Jewell 1974 Azathioprine –maintenance of remission Cyclosporin –induction of remission McCormack G 2002 VanAssche G 2003

Medical Management challenges Uncertain end points Masked sepsis Late relapse –immunosuppression Mallant-Hent 2003

Surgical Issue UC - fragile colon Crohn’s - loss of planes Rectal stump(ed)

Surgical Issue UC - fragile colon Crohn’s - loss of planes Rectal stump(ed)

Surgical Developments One stage reconstruction –cyclosporin Hyde GM 2001 Laparoscopy Hurley BW 2002 Marcello PW interval procedure Reconstruction in Crohn’s disease?

New Challenges? Team management Jewell 1974 –MDM –Shared care –Mixed wards

Patterns of Disease non-IBD Broad spectrum antibiotics –pseudomembranous colitis Multisystem disease –ischaemic colitis Immune-compromised –viral infections –multifactorial disease

Clostridium Difficile 2,000 cases over 10 years 64 colectomies incidence rising – % life threatening cases also doubled –3% Dallal RM,Ann Surg. 2002