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
QUALITY OF CARE AND THE USE OF CARE PATHWAYS
Physician and center-level characteristics are associated with the quality of care and outcomes in ASUC. Gastroenterologists with expertise in IBD are more likely than other gastroenterologists to request appropriate surgical consultation for steroid-refractory patients,69 and inpatients with ASUC primarily cared by gastroenterologists rather than nongastroenterologists have lower in-hospital and one-year mortality.14 Moreover, surgical outcomes differ based on center volume, with higher volume centers having lower rates of postoperative mortality.68,70 However, even at referral centers, key metrics of care quality such as rates of VTE prophylaxis, testing for C. difficile, and timely rescue therapy for steroid-refractory UC patients are suboptimal, with only 70%-82% of patients with IBD hospitalized at four referral centers in Canada meeting these metrics.71
Inpatient clinical pathways reduce LOS, reduce hospital costs, and likely reduce complications.72 For this reason, a consensus group recommended the use of care pathways for the management of ASUC and, although there is little data on the use of pathways for ASUC specifically, the use of such a pathway in the United Kingdom was associated with improved metrics including LOS, time to VTE prophylaxis, testing of stool for infection, CRP measurement, and timely gastroenterologist consultation.16,18
DISCHARGE CRITERIA AND FOLLOW UP
In general, patients should enter clinical remission, defined as resolution of rectal bleeding and diarrhea or altered bowel habits,73 before discharge, and achieving this may require a relatively prolonged hospitalization. Most patients should have one to two bowel movements a day without blood but, at a minimum, all should have less than four nonbloody bowel movements per day. Patients are candidates for discharge if they remain well after transitioning to oral prednisone at a dose of 40-60 mg daily and tolerate a regular diet.
For patients who initiated infliximab during their admission, plans for outpatient infusions including insurance approval should be made before discharge, and patients who started cyclosporine should be transitioned to oral dosing and have stable serum concentrations before leaving the hospital. Patients should leave with a preliminary plan for a steroid taper, which may vary depending on their clinical presentation. Usually, gastroenterology follow-up should be arranged after two weeks following discharge, but patients on cyclosporine need sooner laboratory monitoring.
CONCLUSION
The care of patients with ASUC requires an interdisciplinary team and close collaboration between hospitalists, gastroenterologists, and surgeons. Patients should be treated with intravenous corticosteroids and monitored carefully for response and need for rescue therapy. Establishing algorithms for the management of patients with ASUC can further improve the care of these complex patients.
Disclosures
Drs. Feuerstein, Fudman, and Sattler report no potential conflict of interest.
Funding
This work was not supported by any grant.
