Dr Charabaty reviews her presentation from the Advances in Inflammatory Bowel Diseases regional meeting in Chicago on the key steps for managing the patient with acute severe ulcerative colitis.

Aline Charabaty, MD, is the assistant clinical director of the division of gastroenterology and hepatology at Johns Hopkins School of Medicine in Baltimore, Maryland, and the clinical director of the IBD Center at Johns Hopkins Sibley Memorial Hospital in Washington, DC.

TRANSCRIPT:

Hello everyone. I'm Dr. Aline Charabaty. I'm the assistant clinical director of the division of gastroenterology and hepatology at Johns Hopkins School of Medicine and the clinical director of the IBD Center at Johns Hopkins Sibley Memorial Hospital in Washington, DC. We had fantastic sessions at AIBD Regional in Chicago, and I'm here to share with you tips and pearls on how to approach and manage acute severe ulcerative colitis.

The key message here is, it's important to recognize acute severe ulcerative colitis and recognize that this is a medical emergency, that requires a multidisciplinary care in a hospital setting. The second key point, it's important to act quickly, meaning start therapy early, monitor, involve all the members of the medical team early after admission, including an IBD specialist, gastroenterologist, endoscopist, colorectal surgeon, dietician, infectious disease, if needed. And finally, it's important to monitor and recognize when surgery is indicated in these patients.

So let's start with recognizing acute severe UC. It is defined as having more than 6 bloody bowel movements per day, with systemic toxicity, such as fever, tachycardia, anemia, and increase in inflammatory markers. The new ACG ulcerative colitis activity index includes also an endoscopic assessment; a patient with acute severe UC would have a Mayo score of more than 2 or 3. It is important in the face of acute severe UC to not delay appropriate care and workup, or to prolong any therapy that is not working. So on admission, workup should include regular labs but also blood work that anticipates the need for rescue therapy, such as infliximab or cyclosporine, and also get a baseline CRP, an inflammatory marker to monitor with objective data the response to therapy. Get stool studies to rule out infection, in particular C. Diff infection, and get a flex sig early, within the first 1 or 2 days of admission, to assess a severity of the flare on endoscopy and also to rule out CMV.

Now in term of therapy, we start with IV steroids, solumedrol 60 milligram per day or the equivalent, to control the gut inflammation. But it's also important to remember there are other things that need to be done, including starting DVT prophylaxis. Patients with acute severe UC are at higher risk of clotting, so it's important to start sub-q heparin or Lovenox. The society guidelines now recommend against using wide spectrum antibiotic use, which is something we used to do many years ago, and they do recommend enteral nutrition. So use the gut whenever possible and use it as tolerated by the patients. TPN is not favored because in this patient population, it increases the risk of infection and upper extremity DVTs. Part of the therapy plan should include involving the colorectal surgeon early—even if you think, and you anticipate the medical therapy is going to put the patient in remission, it's important to involve the surgeon early. Let the surgeon meet with the patient, monitor the patient with you, so that if we need to go for surgery, we are already all prepared in the team and the patients are ready for that possibility.

It's important to monitor patient regularly for signs of toxicity, toxic megacolon, perforation, hemorrhages, that would require emergent surgery. Now, like I said before, it's important to act quickly and efficiently and not delay the next potential therapy. So assess the response to IV steroids by day 3. What you want to see is a clinical improvement and a CRP improvement. You want to see a decrease in number of bowel movement, bleeding, and CRP value by 50% compared to baseline. If we don't have such a response, it's important to think about the next step or the rescue therapy, which include surgery, infliximab or cyclosporine. So it really depends on the overall clinical picture, what's going on with the patient. Obviously a patient who's toxic, who's having hemorrhages, who's not doing well, who has deep ulcers on endoscopy, will be better served with surgery. And it's important to not delay surgery when it's needed. Delaying the inevitable will increase the risk of complications for the patient during surgery or after surgery.

Otherwise, our rescue therapy typically is infliximab. Most practices choose infliximab, which has been shown to be effective in inducing remission in acute severe UC, and in decreasing the risk of colectomy in this patient population. But we also have the option of cyclosporine A, and this is a good option in patients who have a history of failure to infliximab or patients who have a contraindication to anti TNF, patients who have very low albumin and we know that are more likely to leak infliximab in their GI tract and not be able to achieve the therapeutic target that we need to induce remission. So this really depends on the clinical situation, the institution, and the gastroenterologist’s experience in choosing infliximab versus cyclosporine as a medical rescue therapy.

But here again, the important thing is to monitor the patient, look for objective and clinical signs of improvement. And if there's no improvement, decide quickly on the next step. Again, recognize when surgery is the right option for the patient and not delay it. So overall act quickly, involve the team, the entire team, early, including the surgeon. Make sure we get a DVT prophylaxis in addition to treating the inflammation adequately and always involve the patient in these conversations, so that at the end of the day, the gastroenterologist, the surgeon, and the patient can make the best decision in that particular case.