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General Reference ⬇

Gastrointest Endosc Clin N Am 2004;33:235

Pathophys and Cause ⬆ ⬇

Cause:Genetic component (Ann IM 1989;110:786)

Pathophys:Begins at rectum, progresses proximally, sometimes involves entire colon, inflammatory changes, spares muscularis, no fistulas/abscesses as with Crohn’s

Epidemiology ⬆ ⬇

Onset age 20-40 yr, occasionally younger (Nejm 1971;285:17). Lower incidence in smokers and other nicotine users! (Nejm 1983;308:361) and in pts s/p appendectomy before age 20 yr (Nejm 2001;344:808)

Signs and Symptoms ⬆ ⬇

Sx:Bloody diarrhea; cramps, poorly relieved with bowel movement; arthritis (20%), esp of hip, knee, ankle, pip joints, and full ankylosing spondylitis syndrome; fever and weight loss

Si:Erythema nodosum; uveitis, though less common than in Crohn's

Course ⬆ ⬇

Depends on rx

Complications ⬆ ⬇

  • Carcinoma (Nejm 1990;323:1228), esp if diffuse disease. May be more malignant than usual colon cancer since it has a 25% 5-yr mortality
  • Strictures
  • Perforation and peritonitis, and/or megacolon
  • Sclerosing cholangitis (Primary Sclerosing Cholangitis) (Ann IM 1985;102:581)
  • Stress and depression result, but do not cause (Ann IM 1991;114:381)
  • PYODERMA GANGRENOSUMin <5% of toxic patients, may occur even when bowel quiescent; present also in RA, IBD, myeloproliferative d/o's, paraproteinemias; must biopsy to be sure not another type of ulcers since steroid rx bad for most other causes (Nejm 2002;347:1412)

r/o other causes of acute diarrhea (Causes of Diarrhea): C. diffcolitis (Pseudomembranous Colitis); ulcerative proctitis, similar disease isolated to rectum, can get above it on sigmoidoscoy, rx w steroid enemas and mesalamine (Rowasa) 500 mg pr bid (Gut 1998;42:195); postcolostomy diversion colitis in empty colorectal segments, rx with instillation of short-chain fatty acids (Nejm 1989;320:23)

Lab and Xray ⬆ ⬇

Lab:

Serol:Ameba titers to r/o before starting steroids if a local risk

Noninv:Colonoscopy; shows pathophysiologic changes described above

Xray:KUB to r/o megacolon (6-8 cm diameter)

Treatment ⬆

Rx:

(Nejm 1996;334:841) Screening and surveillance for Ca:

  • Colonoscopic (Gastrointest Endosc Clin N Am 1997;7:1:129); perhaps q1-2yr with q10cm biopsies for dysplasia after 8-10 yr of pancolitis vs q 5-10 yr unless sx change

of disease:

Salicylates:

  • 5-Aminosalicylic acid (5-ASA) as
    • Coated mesalamine (Asacol) (Ann IM 1991;115:350) 800-1000 mg po tid-qid very effective and works moderately well at 400 mg po bid-qid to prevent recurrence (Ann IM 1996;124:205); $225/mo; or
    • Long-acting Lialda qd (Med Let 2007;49:25); $265/mo; or
    • Retention enema 60-cc to help left-sided disease (Med Let 1988;30:53); or
    • Pentasa 500 mg; $375/mo; or
    • Olsalazine (Dipentum), the 5-ASA dimer, 500 mg po bid up to 1 gm bid; adverse effects: diarrhea (Med Let 1990;32:103); cost $25/wk; or
    • Balsalazide (Colazal) (Med Let 2001;43:62), a precursor; 2.25 gm po tid, $400+/mo
  • Sulfasalazine (Azulfidine) as 500-mg tabs, 2-4 gm po qd (Ann IM 1984;101:377) or more up to 12 gm qd; active metabolite is 5-aminosalicylic acid (5-ASA); prophylactically keeps disease in remission (25% recur/yr—Lancet 1992;339:1279); at $30-50/mo, much cheaper than 5-ASA meds; adverse effects (increased when >4 gm qd in slow acetylators—Nejm 1973;289:491): allergic worsening of sx (Nejm 1982;306:409); rash, can be desensitized with increasing doses (Ann IM 1984;100:512)

Infliximab (Remicade) iv q 8 wk induces and maintains remissions (Nejm 2005;353:2462)

6-MP if can’t get off steroids; some small cancer risk as well as reversible problems (Ann IM 1989;111:642); cyclosporine 4 mg/kg iv qd helps 80% within 1 wk of those who fail iv steroids for a week when flaring (Nejm 1994;330:1841)

Steroid enemas or systemically, eg, prednisone 60-80 mg po qd, or ACTH 120 U/24 h iv for severe flare; chronically try to get off entirely, at least <10 mg po qd to minimize adverse effects (Disease Modifying Antirheumatic Drugs)

Ciprofloxacin? (Gastroenterology 1998;115:1072) 500-750 mg po bid × 6 mos for resistant flares

Nicotine 14+-mg patch qd helps many (Ann IM 1997;126:364; Nejm 1994;330:811, 856) during acute phase only, does not prevent recurrences (Nejm 1995;332:988)

Surgical colectomy with ileostomy usually cures, although when this should be done is debatable; but for recurrent flares, must do if both iv steroid and iv cyclosporine fail (Nejm 1994;330:1841)