Case 9 Discussion - IBD Learn

Learning Objectives

Differentiate between various causes of diarrhea
Carry out a thorough workup of inflammatory bowel disease
Choose between appropriate therapies for acute severe ulcerative colitis
Determine next steps when initial treatment for UC fail

EPAs

EPA 1: Classify IBD phenotype, disease activity, and extraintestinal manifestations
EPA 2: Use advanced diagnostic and therapeutic endoscopic and radiographic techniques in the management of IBD
EPA 3: Prescribe and manage evidenced-based IBD therapies using clinical pharmacologic principles in clinical practice
EPA 5: Manage hospitalized patients with IBD

Discussion

The diagnosis of ulcerative colitis is reliant on clinical history, laboratory, endoscopic, and histologic findings. Differentiating ulcerative colitis from Crohn’s disease can often be challenging; however, there are some distinguishing features that aid the clinician in making a diagnosis. Ulcerative colitis tends to extend proximally in a contiguous and circumferential fashion, often with an abrupt cut-off point between diseased and uninvolved mucosa. An isolated area of involvement in the cecum, typically around the area of the appendiceal orifice may be involved in ulcerative colitis (a “cecal patch”). Additionally, circumferential ileitis may be present in ulcerative colitis (“backwash ileitis”). The presence of granulomatous inflammation on histopathology is more consistent with Crohn’s disease. It is important to accurately identify the disease phenotype, as this has some implications for available therapies (e.g., some therapies are only FDA approved for ulcerative colitis, but not Crohn’s disease), surgical candidacy, and clinical trial eligibility. (NASPGHAN, 2007)

Severity of ulcerative colitis can be calculated by using the Truelove and Witts score.

Truelove and Witts Criteria

	Mild	Moderate	Severe
Bowel Movements/day	<4	4-6	>6
Blood in Stool	Intermittent	Frequent Blood	Continuous visible blood
Temperature > 37.5 _^oC	No	No	Yes
Heart Rate > 90	No	no	Yes
Anemia (Hgb <10.5 g/dL)	No	No	Yes
ESR (mm/hr) or CRP (mg/L)	Normal	Normal	Elevated

Adapted from Truelove SC, Witts LJ. Cortisone in ulcerative colitis; final report on a therapeutic trial. Br Med J. 1955 Oct 29;2(4947):1041-8. doi: 10.1136/bmj.2.4947.1041. PMID: 13260656; PMCID: PMC1981500.

While active severe disease is an indication for hospital admission, other factors may also require admission to the hospital. Toxic megacolon, failure of outpatient therapy, complications of disease (e.g. VTE), complications of treatment (e.g. opportunistic infections), and severe extraintestinal manifestations (e.g. diffuse pyoderma gangrenosum) are additional indications for hospital admission. Inadequate nutrition and hydration should also be considered when deciding if a patient needs to be hospitalized. (Lamb, et al., Gut, 2019)

Prior to starting IV methylprednisolone, it is advisable to rule out concomitant C. Difficile infection as a trigger for the patient’s flare, so as not to precipitate more severe C. Difficile colitis. Prior to starting rescue therapy, patients must be evaluated for latent tuberculosis and hepatitis B infection. In appropriate patient population, HIV screening may also be considered. As many rescue therapies are weight-based, obtaining a patient weight is necessary prior to administering rescue therapy. Abdominal imaging is important to assess for colonic dilatation and to evaluate for impending toxic megacolon and should be obtained early in the disease course. Early imaging also provides a readily available comparison should the patient have worsening abdominal pain requiring reexamination with imaging. Flexible sigmoidoscopy is important to evaluate for evidence of CMV colitis (which cannot be easily detected on serologic testing). It is also important to verify endoscopic activity of disease to ensure that patient’s symptoms are not related to another process (e.g. bleeding hemorrhoids, irritable bowel syndrome). (Pola, et al., CGH 2012)

Patients should be monitored daily for response to therapy and to ensure that high quality care is being delivered to the patient. Medications should be reviewed to ensure that medications that could precipitate colonic dilatation and inflammation are avoided. Specifically, opiates, anticholinergic medications, and NSAIDs should be avoided. Tramadol (partial opiate agonist) and acetaminophen may be safely used. Pharmacologic prophylaxis against venous thromboembolism should be given daily, even if bloody bowel movements are present if the patient is hemodynamically stable. A daily checklist reviewing these quality metrics may help improve adherence to evidence-based care. (Lewin & McConnell, et al., IBD 2019)

After three days of IV corticosteroids, the Travis and Ho Indices should be calculated.

Adapted from: Ho GT, *et al*. Predicting the outcome of severe ulcerative colitis: development of a novel risk score to aid early selection of patients for second‐line medical therapy or surgery. *Aliment Pharmacol Ther* 2004; 19 and Travis SPL, *et al*. Predicting outcome in severe ulcerative colitis. *Gut* 1996; 38: 905–10.

Individuals with high risk of steroid failure should receive rescue therapy with either cyclosporine (if local expertise is available) or infliximab. The standard dose of infliximab is 5 mg/kg, though individuals at high risk for infliximab failure (e.g., low albumin) may benefit from infliximab 10 mg/kg. (Chao, et al. Dig Dis Sci 2019). Tofacitinib 10 mg twice daily has been studied as an additional rescue therapy (Kotwani, et al., J Crohns Colitis 2020), though no large-scale studies of this practice exist to date. If a patient fails to respond to IV steroids and rescue therapy, colorectal surgery consultation is advised early in the process to follow and counsel the patients so that an informed decision can be made before colectomy is the only reasonable choice. Additional rescue therapies are not recommended. The sequential use of cyclosporine followed by infliximab or vice versa does not improve colectomy-free survival, and it appears to be associated with a high rate of serious adverse events (Maser, et al. CGH, 2008)

Sources:

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