Millie Long, MD, on Acute Severe Ulcerative Colitis

Dr Long discusses the management of acute severe ulcerative colitis, including initiating therapy, when and how to assess response, options for rescue treatment, and the role of the surgeon in determining the best course of care.

Millie Long, MD, is a professor of medicine, vice chief of education, and director of the fellowship program in the Division of Gastroenterology and Hepatology at the University of North Carolina at Chapel Hill.

Hi, this is Millie Long. I'm from University of North Carolina, nd today I gave a talk on acute severe ulcerative colitis.

This is something that we see commonly in our practices. You know, up to about 20% of patients with ulcerative colitis will have an episode of acute severe colitis,  ulcerative colitis, where they will require hospitalization.

And this becomes really important because it is a very timely intervention. We need to assess the patient, assess their disease activity, manage them appropriately during the course of this hospitalization to try to really turn things around for them. When we think about acute severe ulcerative colitis, it's a combination of symptoms, you know, obviously severe ongoing diarrhea, bleeding, but also some signs of toxicity. They may even have fever or abdominal pain. What we want to avoid is colonic dilation or toxic megacolon. So when patients have these symptoms, they require hospitalization and intense observation and really initiation of therapy.

And so IV corticosteroids are the mainstay of therapy, but we need to really reassess quite early to understand if they're having a response and then move on to rescue therapy. And that very early time period, there's some really important things to get done. You really want to rule out any other infectious process, including C. difficile or CMV, and treat that concurrently with treating their underlying colitis. You really want to do at least a flexible sigmoidoscopy where you're assessing the severity of the inflammation and the distribution. That really is important and has a lot of prognostic factors in terms of the outcome for that individual patient.

We often use the Mayo score, which ranges from 0 to 3 to help to assess severity, and it's important to document that, and you can use that as a yardstick, particularly for those Mayo3 patients. Those are patients that you really want to upfront get them on effective therapy to help to turn that disease process around. So that short leash with those IV corticosteroids, really monitoring that CRP daily, doing a daily abdominal exam. So you're seeing if they do have a response to then add a rescue therapy if needed.

The other aspect with the early management of these patients is really to get the colorectal surgeon involved early. In fact, we often involve them in the first 24 hours of the admission. This helps the patient to meet the surgeon to kind of as they're being treated medically, kind of have continued conversations with the surgeon and recognize the role that surgery can play to really save their lives if needed and to give them back a quality of life if they're not responding to that medical therapy.

We talked about medical options and the 2 with the highest level of data include infliximab as rescue therapy for the corticosteroid resistant patient or cyclosporin. And cyclosporin is one that does need intensive monitoring. You need to check levels and really kind of need an expert level of expertise at the center.

With infliximab, you really want to be careful about that severe patient, because if the albumin is low and the patient is quite ill, they may actually waste that infliximab in their stool, and you might not be able to get to a therapeutic level. So those are the patients where you're really watching them carefully, monitoring that CRP, potentially using somewhat accelerated dosing of the infliximab—we have some data that that may help short-term-term in preventing colectomy, and really trying to optimize the drug.

So, you know, there's a lot going on in acute severe ulcerative colitis. We also still want to think about those complications that can arise just from the hospitalization itself. In other words, DVTs are common, PTEs are common, get those patients on prophylaxis very early, and really think about nutrition. You don't want your patients starving themselves, and that's the reason their bowel movement frequency is somewhat reduced. We do want them eating and having good nutrition during this time period as well.

So when you put it all together, it's a multidisciplinary management where you've got working with the gastroenterologist, the colorectal surgeon, the nutritionist, you know, you're really bringing the expertise of the team together to provide that best practice for the individual patient with acute severe ulcerative colitis. And in reality, about 15% of patients over 10% of patients will end up with colectomy and often have, you know, wonderful outcomes. And so this is something that we really do need to offer as an upfront option and really help our patients to understand when the safest option is really to move on to surgery.

So with that, I'd like to thank you for joining me on this brief recap of my talk on acute severe ulcerative colitis and really check out the AIBD network for more great content.

Thank you.