1. Ulcerative colitis

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

3. 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

5. 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

6. 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

7. Treatment of ulcerative colitis:
Extensive colitis:
Mild to moderate:
Sulfasalazine, 1.5-3g orally twice daily., or
Mesalamine tablets (delayed release), g/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

8. 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

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

10. 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

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

12. 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

13. 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.

14. Refractory disease: Mercaptopurine Azathioprine Transdermal nicotine
Infliximab