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
Bowel rest with parenteral nutrition does not improve outcomes in ASUC versus an oral diet, and there is no contraindication to allowing patients to continue on a regular diet unless they have toxic megacolon or other signs of fulminant colitis.49,50 However, patients may feel better eating less, as this will reduce their bowel movement frequency. Unfortunately, this can give a false sense of reassurance that the patient is improving. Therefore, it remains important to evaluate a patient’s symptoms in the context of their food intake.
Assessing Response to Steroids
Patients who do not respond adequately to the first-line intravenous steroid therapy will require medical or surgical rescue therapy; therefore, deciding whether a patient has responded is essential. Patients should have less than four bowel movements per day – ideally just one to two – with no blood to indicate a complete response. For more ambiguous situations, although there is no strict definition of steroid responsiveness, multiple prediction indices have attempted to identify patients who will require rescue therapy. One of the simplest, the Oxford index, illustrates two of the most critical parameters to follow, stool frequency and CRP.51 In a preinfliximab cohort, Oxford index predicted an 85% likelihood of colectomy in patients with eight or more daily bowel movements or with three to eight daily bowel movements and a CRP greater than 45 mg/L after three days of intravenous steroid treatment.52 To assist with assessing responsiveness to therapy, we ask patients to log their bowel movements – either on paper or on a whiteboard in the hospital room – so that we can review their progress daily. Other predictors of colectomy include hypoalbuminemia, scoring of endoscopic severity, and colonic dilation.53
Patients who fail to respond to intravenous corticosteroids after three days33,35 of treatment should be started on rescue therapy with infliximab or cyclosporine or undergo colectomy. A common pitfall in the treatment of ASUC is waiting for a response to steroids beyond this time frame, after which patients are unlikely to benefit.34,36 Furthermore, patients for whom surgical rescue therapy is delayed have higher operative morbidity and mortality.54,55 Because timely decision making regarding rescue therapy is crucial to optimizing outcomes, patient education efforts regarding potential rescue therapy should take place on admission or soon after, rather than waiting to ascertain steroid responsiveness.
RESCUE THERAPY FOR STEROID-REFRACTORY DISEASE
Medical options for rescue therapy include the antitumor necrosis factor (anti-TNF) agent infliximab or the calcineurin inhibitor cyclosporine. In general, infliximab and cyclosporine have been found to be roughly equivalent in efficacy in clinical trials regarding response, remission, and colectomy at 12 months.56,57 However, many clinicians prefer infliximab due to its relative ease of use, familiarity with the agent from outpatient experience, and ability to continue to use long term for maintenance of disease remission.58 In contrast to infliximab, intravenous cyclosporine requires closer monitoring and labs to assess the therapeutic trough level. The decision regarding which drug to use should be made on a case-by-case basis in conjunction with a gastroenterologist experienced in their use, and if no such specialist is available, transfer to a specialized center should be considered. Generally, successive treatment with cyclosporine or infliximab followed by third-line salvage therapy with the other drug should be avoided due to low rates of response and high rates of adverse events.59
