1. Fulminant Colitis New Challenges M62 Coloproctology course 2004

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

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

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

5. Patterns of Disease UCCrohn’s

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

7. Pseudomembranous colitis Rising incidence 30-100%/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 23006460% Hosp 1575120% NOF 2391735% Gastro1338%

8. Pseudomembranous colitis Immunosupression –Lung TT CT diagnosis

9. Cardiac Patients Major GI complications- high mortality Surgical decisions - complex –Cardiac surgery: scope: stool cultures CentreNrs GI Compl C- diff Isc- aemia Mort Texas11,000147181722% Frankf.1,0002385%

10. 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

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

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

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

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

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

17. New Challenges? Team management Truelove @ Jewell 1974 –MDM –Shared care –Mixed wards

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

19. Clostridium Difficile 2,000 cases over 10 years 64 colectomies incidence rising –0.6 - 1.2% life threatening cases also doubled –3% Dallal RM,Ann Surg. 2002