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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

Monday, August 7, 2017

Ulcerative Colitis - ED Management

Ulcerative colitis (UC) is a chronic inflammatory relapsing and remitting disease of the colon. The etiology is believed to be autoimmune with some genetic component. Peak incidence occurs in the second and third decades of life with characteristic symptom of bloody diarrhoea. The rectum is almost always involved in UC. 

Factors associated with an unfavourable prognosis include higher severity and extent of disease, a short interval between attacks, systemic symptoms, and onset of the disease after 60 years of age.


Clinical Presentation

Crampy abdominal pain, bloody diarrhea, and tenesmus are typical symptoms of UC. The disease is classified as mild, moderate, or severe depending on the clinical manifestations. 

Truelove and Witts criteria


Extra intestinal Manifestations 



Diagnosis

ED diagnosis of ulcerative colitis rests on the following: 
History of abdominal cramps and diarrhea, mucoid stools, stool examination negative for ova and parasites, stool cultures negative for enteric pathogens, and confirmation of diagnosis by colonoscopy.




Treatment


Mild to Moderate attacks
Most of these patients can be treated as outpatients. A combination of oral (2.4 grams/day) and topical mesalamine is used. Topical glucocorticoid enemas or Mesalazine enemas or suppositories (500 milligrams twice a day) are quite effective in distal proctosigmoiditis and have lower systemic side-effect profiles.

If topical therapy is unsuccessful, steroids (40-60md Prednisolone/day) are effective in inducing a remission in the majority of cases. Antidiarrheal agents are generally ineffective and may precipitate toxic megacolon.


Rx of UC based on severity of disease

Severe ulcerative colitis - Treat with IV steroids, fluids, correct electrolyte abnormalities, broad-spectrum antibiotics, melamine. IV cyclosporine (2-4 milligrams/kg per day) or infliximab (5 milligrams/kg) can be effective in fulminant colitis nonresponsive to IV steroids.



Complications
  • LGI Bleed (Most Common)
  • Toxic Megacolon The most feared complication of ulcerative colitis is the development of toxic megacolon. TM occurs as a result of extension of the inflammation beyond the submucosa, causing loss of contractility and dilated colon. Dilation of the colon is associated with a worsening of the clinical condition and development of fever and prostration. Patients with Toxic Megacolon appear toxic with distended, tender and tympanic abdomen. They typically present with fever, tachycardia and shock.

Plain radiography of the abdomen demonstrates a long, continuous segment of air-filled colon greater than 6 cm in diameter. Loss of colonic haustra represent bowel wall edema. Occasionally, features of toxic megacolon, such as leukocytosis, anaemia, dyselectrolytemia, hypoalbuminemia and peritonitis, can be masked in the patient taking corticosteroids.  


Antidiarrheal agents, hypokalemia, narcotics, cathartics, pregnancy, enemas, and recent colonoscopy have been implicated as precipitating factors in toxic megacolon. Rx with nasogastric suction, IV steroids, broad-spectrum antibiotics active against coliforms and anaerobes, and IV fluids. Get a surgical consultation ASAP.
  • Perforation
  • Bowel Obstruction (due to strictures)
  • Carcinoma Colon  (Advanced and prolonged disease)
  • Perirectal fistulas and abscesses 

Disposition
Fulminant attacks of ulcerative colitis need hospitalization for fluid and electrolyte management and careful observation for the development of complications. Patients with complications such as GI Bleed, toxic megacolon, and bowel perforation should also be admitted. In addition to toxic megacolon, the indications for surgery include colonic perforation, massive lower gastrointestinal bleeding, suspicion of colon cancer, and disease that is refractory to medical therapy (large doses of steroids required to control the disease). 

Patients with mild to moderate disease can be discharged from the ED.  It is crucial to arrange close follow-up with gastroenterologist, and any adjustment in medical therapy should be discussed prior to discharge.


References:
  1. https://clinicalgate.com/toxic-megacolon/
  2. Oxford Handbook of Clinical Medicine
  3. Tintinalli's textbook of EM - 8th Edition
  4. http://fromnewtoicu.com/blog/2016/12/28/toxic-megacolon-1
Posted by:



              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic


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