Clinical suspicion and diagnosis
The most important symptom is bloody diarrhoea and proctoscopy and biopsy is the single most useful tool in diagnosis and follow up. Barium enema is useful in evaluating the extent & should never be performed during an acute attack.
During active disease
Mild to moderate disease aminosalicylates are the drug of choice
- Sulfasalazine 0.5-1 gm PO qid then maintain on 1 gm bid. Sulfasalazine reaches the colon intact where it is metabolised into sulfapyridine moeity (responsible for toxicity) and 5-ASA (active component)
- 2. 5-aminosalicylates 0.5-1 gm PO qid then maintain on 500mg qid these preparations lack the sulfa moiety and are classified according to where they are active.
Moderate to severe disease (>5 motions per day) usually requires treatment with glucorticoids. Prednisone PO 10-40 mg qd then maintain on 1 gm bid.
Indications of glucorticoids in UC:
- moderate to severe cases - maybe used in conjunction with aminosalicylates
- Hydrocortisone enemas in ulcerative proctitis until symptoms subside then put on aminosalicylates.
- Extraintestinal manifestations
If symptoms persist then hospitalisation and treat with IV hydrocortisone (100 mg q 6hrs) or methylprednisolone (20-40 mg q 12hrs).
- 6MP, azathioprine are used only in the maintenance phase to reduce the amount of glucorticoids in patients with moderate to severe disease and with a contraindication to surgery.
- Cyclosporine is effective in acute exacerbations in patients unresponsive to standard intensive medical treatment. Nephrotoxic.
Antidiarrheal agents and anticholinergics
Symptomatic therapy for colics.
Normal diet when in remission and low fiber diet when during an exacerbation.
Treatment of complications:
Toxic megacolon and fulminant disease:
- Toxic megacolon occurs in 1-2% of patients: it is diagnosed when radiographically midtransverse colon appears > 6cm in diameter + toxic symptoms
- nasogastric suction - nothing by mouth and TPN
- correct water - electrolyte disturbances
- Antibiotics IV
- IV glucocorticoids
- total colectomy for acutely ill not responding within 48 hrs.
- avoid anticholinergics and opioids as they precipitate and aggrevate toxic megacolon.
Colonic cancer may require therapy with surgery if feasible and chemotherapy is appropriate.
Barium enema and colonoscopy are not done during acute attacks of ulcerative colitis for fear of precipitating an acute toxic dilatation of the colon.