Management of difficult inflammatory bowel disease: where are we now?

Table 1 Principles of management of acute severe ulcerative colitis

GENERAL MEASURES

Explanation, psychosocial support

- patient support groups

Specialist multidisciplinary care

- physicians, surgeons, nutrition team, nurses, stoma therapist, counsellor

ESTABLISHING THE DIAGNOSIS, EXTENT/SITE AND SEVERITY

- clinical evaluation

- FBC, ESR, C reactive protein, albumin, LFTs, amoebic serology

- stool microscopy, culture, C. difficile toxin

- limited sigmoidoscopy and biopsy

- plain abdominal X-ray

- consider radiolabelled leucocyte scan

MONITORING PROGRESS

- daily clinical assessment

- stool chart

- 4-hrly temperature, pulse

- daily FBC, ESR, C-reactive protein, urea and electrolytes, albumin

- daily plain abdominal X-ray

SUPPORTIVE TREATMENT

- i.v. fluids, electrolytes (Na, K), blood transfusion

- nutritional supplementation

- heparin s.c.

- haematinics (folate)

-avoid antidiarrhoeals (codeine, loperamide, diphenoxylate), opiates, NSAIDs

- rolling manoeuvre (if colon dilating)

SPECIFIC TREATMENT

Medical - corticosteroids i.v. (hydrocortisone or methylprednisolone) then p.o. (prednisolone)

-continue 5-ASA p.o. in patients already taking it; otherwise start when improvement begins

-antibiotics for very sick febrile patients, or when infection suspected

-consider cyclosporin i.v. then p.o.) for steroid non-responders at 4-7 d

Surgical (for non-responders at 5-7 d, toxic megacolon, perforation, massive haemorrhage)

- panproctocolectomy with ileoanal pouch or permanent ileostomy

- subtotal colectomy with ileorectal anastomosis (rarely)