Inpatient Management of Acute Severe Ulcerative Colitis
Acute severe ulcerative colitis (ASUC) is a potentially life-threatening presentation of ulcerative colitis that in nearly all cases requires inpatient management and coordinated care from hospitalists, gastroenterologists, and surgeons. Even with ideal care, a substantial proportion of patients will ultimately require colectomy, but most patients can avoid surgery with intravenous corticosteroid treatment and if needed, appropriate rescue therapy with infliximab or cyclosporine. In-hospital management requires not only therapies to reduce the inflammation at the heart of the disease process, but also to avoid complications of the disease and its treatment. Care for ASUC must be anticipatory, with patient education and evaluation starting at the time of admission in advance of the possible need for urgent medical or surgical rescue therapy. Here we outline a general approach to the treatment of patients hospitalized with ASUC, highlighting the common pitfalls and critical points in management.
© 2019 Society of Hospital Medicine
INITIAL EVALUATION
The multifaceted initial inpatient evaluation of patients with ASUC aims to assess disease severity, identify and prevent potential complications, and initiate planning for potential failure of first-line pharmacologic therapy. Due to the accumulating evidence that involving physicians with expertise in managing ASUC improves outcomes, gastroenterologists should be involved in the care of patients with ASUC from the time of their admission.14,15 Additionally, creating standardized care pathways for the management of ASUC can reduce cost, LOS, and improve quality.16
History and Physical Examination
Patients should be asked about fever, abdominal pain, nausea, emesis, bloating, weight loss, and bowel movements (frequency, consistency, the presence of blood, urgency, nighttime awakenings). The number of bowel movements over a 24-hour period should be quantified as this helps assess the overall disease severity (Table 1).
The patient’s initial inflammatory bowel disease (IBD) history is also essential. The review of pertinent information regarding the patient’s initial diagnosis of UC includes the severity and anatomic extent of disease, extraintestinal manifestations, previous medical therapies, and surgical interventions. Exposure to nonsteroidal anti-inflammatory drugs (NSAIDs) or antibiotics should be identified as they may precipitate flares.17 Travel history may be pertinent as travel increases the risk of infections with food-borne or parasitic pathogens.18
Physical examination begins with an assessment of vital signs and volume status. Abdominal examination should include evaluation of bowel sounds, an assessment of distention, location, the extent of abdominal tenderness, and peritoneal signs. The abdominal exam should be interpreted in the context of the patient’s medications, as the use of steroid or analgesic therapies may affect the sensitivity for detecting complications. An external rectal exam evaluating perianal disease should be performed, as perianal disease raises concern for Crohn’s, a disease whose surgical management differs from UC.
A careful exam for extraintestinal manifestations is also essential. The skin should be evaluated for any new rashes, especially on the anterior shin consistent with erythema nodosum or ulcerated lesions on the skin suggestive of pyoderma gangrenosum. The peripheral joints should also be examined for any synovitis. Additional examinations should be performed based on any reported symptoms (eg, the ophthalmic exam for uveitis or scleritis if visual changes or eye pain are reported). Some extraintestinal manifestations require subspecialty consultation and comanagement to guide disease therapy. Patients with underlying pyoderma gangrenosum may require a dermatology consultation to guide management. Ocular inflammation requires ophthalmology involvement, and inflammatory arthritis is best comanaged with rheumatology.19
Laboratory Testing
Initial testing should include a complete blood count with differential, basic metabolic panel, and liver chemistries including alkaline phosphatase and albumin. When relevant, pregnancy testing should be performed. Measure CRP on admission so that its trajectory can be followed during therapy. However, a normal CRP does not exclude the presence of a UC flare as a subset of patients with ASUC will have a normal CRP despite severe mucosal inflammation.20
Since one-third of patients do not respond to intravenous corticosteroids and will require rescue therapy during the hospitalization with infliximab or cyclosporine, anticipatory testing for these medications should be performed on admission to avoid delays in the administration of rescue therapy.6,21 This should include an interferon-gamma release assay (eg, quantiferon gold) to test for latent tuberculosis and hepatitis B serologies in anticipation of possible treatment with infliximab. An interferon-gamma release assay is preferred to a tuberculin skin test because patients may be anergic, and a skin test does not provide a control to determine whether a negative test is due to anergy. In contrast, although a quantiferon gold test can be indeterminate in ASUC due to disease activity and systemic steroids, the results indicate if the patient is anergic so that one will not rely on a false-negative result. In the event of an equivocal result, a careful clinical assessment for risks of TB exposures should be elicited, and a chest radiograph should be obtained.22 In patients with prior high risk of tuberculosis exposures or a positive test for tuberculosis, an infectious disease specialist should be consulted early to advise if therapy should be started in preparation for the potential use of infliximab.23 In cases where cyclosporine may be considered, magnesium and total cholesterol level should be checked. Sending thiopurine methyltranferase (TPMT) enzyme activity should be considered as well, in case of a need for future thiopurine use for maintenance of disease activity.24
Infectious diarrhea may be indistinguishable from ASUC and may also be the trigger of a flare; thus, it is important to rule out infection with stool microbiologic studies. Most importantly, Clostridium difficile infection must be ruled out in all patients with ASUC. Although patients with IBD, especially those with UC, have significantly higher rates of asymptomatic C. difficile carriage than the general population, a positive polymerase chain reaction test for C. difficile in a patient with ASUC should prompt treatment with oral vancomycin.25 However, if carriage if suspected and a subsequent enzyme-linked immunoassay for C. difficile toxin is negative, treatment can be discontinued. Active C. difficile infection in patients with IBD is associated with increased disease severity, greater length of hospital stay, and increased the likelihood of colectomy and mortality.26,27 Other bacterial infections including Escherichia coli, Campylobacter, Shigella, Salmonella, Yersinia, Entamoeba histolytica, as well as other parasitic infestations may mimic UC. Testing should be considered in cases of foreign travel, immunosuppression or contact with other persons with diarrhea.7,28 Routine testing of these other enteric infections without a clear exposure risk is of little benefit and may raise costs.23,29
