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Update on medical and surgical options for patients with acute severe ulcerative colitis: What is new?

View Article: PubMed Central - PubMed

ABSTRACT

Acute severe ulcerative colitis (UC) is a highly morbid condition that requires both medical and surgical management through the collaboration of gastroenterologists and colorectal surgeons. First line treatment for patients presenting with acute severe UC consists of intravenous steroids, but those who do not respond require escalation of therapy or emergent colectomy. The mortality of emergent colectomy has declined significantly in recent decades, but due to the morbidity of this procedure, second line agents such as cyclosporine and infliximab have been used as salvage therapy in an attempt to avoid emergent surgery. Unfortunately, protracted medical therapy has led to patients presenting for surgery in a poorer state of health leading to poorer post-operative outcomes. In this era of multiple medical modalities available in the treatment of acute severe UC, physicians must consider the advantages and disadvantages of prolonged medical therapy in an attempt to avoid surgery. Colectomy remains a mainstay in the treatment of severe ulcerative colitis not responsive to corticosteroids and rescue therapy, and timely referral for surgery allows for improved post-operative outcomes with lower risk of sepsis and improved patient survival. Options for reconstructive surgery include three-stage ileal pouch-anal anastomosis or a modified two-stage procedure that can be performed either open or laparoscopically. The numerous avenues of medical and surgical therapy have allowed for great advances in the treatment of patients with UC. In this era of options, it is important to maintain a global view, utilize biologic therapy when indicated, and then maintain an appropriate threshold for surgery. The purpose of this review is to summarize the growing number of medical and surgical options available in the treatment of acute, severe UC.

No MeSH data available.


Related in: MedlinePlus

Algorithm for treatment of acute severe ulcerative colitis. UC: Ulcerative colitis; TAC: Total abdominal colectomy; IPAA: Ileal pouch-anal anastomosis; CBC: Complete blood count; CMP: Comprehensive metabolic panel; ESR: Erythrocyte sedimentation rate; CRP: C-reactive protein.
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Figure 1: Algorithm for treatment of acute severe ulcerative colitis. UC: Ulcerative colitis; TAC: Total abdominal colectomy; IPAA: Ileal pouch-anal anastomosis; CBC: Complete blood count; CMP: Comprehensive metabolic panel; ESR: Erythrocyte sedimentation rate; CRP: C-reactive protein.

Mentions: Patients with acute severe UC require constant reassessment, with antibiotic administration in the setting of infection, total parenteral nutrition in the setting of malnutrition, and escalation of therapy to medication non-responders. Kedia et al[12] proposed an algorithm for reassessing patient steroid response at days 1, 3 and 4-7 in which incomplete responders and non-responders either advance to rescue therapy or proceed to colectomy. In this algorithm, the Oxford criteria (> 8 stools/d or > 3 stools/d with a CRP > 45 mg/L) are used to determine the need for escalation of therapy[13]. With careful attention to the patient’s physical condition and severity of illness, the appropriate medical or surgical therapy can be selected to target the individual’s ever-changing disease (Figure 1).


Update on medical and surgical options for patients with acute severe ulcerative colitis: What is new?
Algorithm for treatment of acute severe ulcerative colitis. UC: Ulcerative colitis; TAC: Total abdominal colectomy; IPAA: Ileal pouch-anal anastomosis; CBC: Complete blood count; CMP: Comprehensive metabolic panel; ESR: Erythrocyte sedimentation rate; CRP: C-reactive protein.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5037332&req=5

Figure 1: Algorithm for treatment of acute severe ulcerative colitis. UC: Ulcerative colitis; TAC: Total abdominal colectomy; IPAA: Ileal pouch-anal anastomosis; CBC: Complete blood count; CMP: Comprehensive metabolic panel; ESR: Erythrocyte sedimentation rate; CRP: C-reactive protein.
Mentions: Patients with acute severe UC require constant reassessment, with antibiotic administration in the setting of infection, total parenteral nutrition in the setting of malnutrition, and escalation of therapy to medication non-responders. Kedia et al[12] proposed an algorithm for reassessing patient steroid response at days 1, 3 and 4-7 in which incomplete responders and non-responders either advance to rescue therapy or proceed to colectomy. In this algorithm, the Oxford criteria (> 8 stools/d or > 3 stools/d with a CRP > 45 mg/L) are used to determine the need for escalation of therapy[13]. With careful attention to the patient’s physical condition and severity of illness, the appropriate medical or surgical therapy can be selected to target the individual’s ever-changing disease (Figure 1).

View Article: PubMed Central - PubMed

ABSTRACT

Acute severe ulcerative colitis (UC) is a highly morbid condition that requires both medical and surgical management through the collaboration of gastroenterologists and colorectal surgeons. First line treatment for patients presenting with acute severe UC consists of intravenous steroids, but those who do not respond require escalation of therapy or emergent colectomy. The mortality of emergent colectomy has declined significantly in recent decades, but due to the morbidity of this procedure, second line agents such as cyclosporine and infliximab have been used as salvage therapy in an attempt to avoid emergent surgery. Unfortunately, protracted medical therapy has led to patients presenting for surgery in a poorer state of health leading to poorer post-operative outcomes. In this era of multiple medical modalities available in the treatment of acute severe UC, physicians must consider the advantages and disadvantages of prolonged medical therapy in an attempt to avoid surgery. Colectomy remains a mainstay in the treatment of severe ulcerative colitis not responsive to corticosteroids and rescue therapy, and timely referral for surgery allows for improved post-operative outcomes with lower risk of sepsis and improved patient survival. Options for reconstructive surgery include three-stage ileal pouch-anal anastomosis or a modified two-stage procedure that can be performed either open or laparoscopically. The numerous avenues of medical and surgical therapy have allowed for great advances in the treatment of patients with UC. In this era of options, it is important to maintain a global view, utilize biologic therapy when indicated, and then maintain an appropriate threshold for surgery. The purpose of this review is to summarize the growing number of medical and surgical options available in the treatment of acute, severe UC.

No MeSH data available.


Related in: MedlinePlus