OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• inflammatory bowel disease (IBD)

• annual incidence in USA 1 case per 1000 white adults and rising
• affects all age groups, esp. 3rd & 4th decades of life
• almost exclusive to industrialised nations with urban > rural
• FH UC in 10-15%
• whites 4x risk cf non-whites
• M=F although increased risk if on OCP
• outside the tropics, it is the commonest cause of prolonged bloody diarrhoea

• inflammatory reaction of the mucosa of the colon:
  • always arises 1st in the rectum
  • rectum is only part involved in 10-38% cases
  • pancolitis occurs in 10% cases
  • uniformly continuous disease process with no skip lesions
• mucosal appearance:
  • thick inflammatory exudate of pus, blood, mucus covering irregular shallow ulcers interspersed with islands of swollen mucosa (“pseudopolyps”)
  • increased mucosal friability
  • microscopic “crypt abscesses”
• chronic disease results in colon becoming rigid, foreshortened tube lacking haustral markings

• sacroiliitis, ankylosing spondylitis, cholangitis, hepatitis, hepatitis, amyloid
• colonic Ca

• chronic insidious recurrent abdominal pain, anorexia, weight loss, mild diarrhoea
• acute onset of bloody diarrhoea, abdo. pain, +/- tenesmus, vomiting & fever

• often associated with:
  • emotional stress, infections, other acute illnesses
  • pregnancy, dietary indiscretions, use of cathartics or antibiotics
  • withdrawal of anti-inflammatory or steroid Rx
• extraGIT manifestations may be present in up to 20% cases:
  • peripheral arthritis, apthous ulcers, erythema nodosum, pyoderma gangrenosum

• occurs in 10-15% pts
• parameters suggestive of this:
  • > 6-8 stools per day
  • anaemia - H'crit < 30% (may not be evident until after rehydration)
  • T > 38deg C
  • LOW > 10% of premorbid weight
  • tachycardia
  • erythrocyte sedimentation rate (ESR) > 30
  • se albumin < 30g/L
  • failure of usually effective Rx regimes
  • failure of 5-7 day course of intensive outpatient Rx

• a manifestation of fulminant disease which usually occurs during initial acute episode
• mainly involves transverse colon causing:
  • septic, apathetic, lethargic looking pt
  • high fever, chills, tachycardia
  • progressive abdoinal pain, tenderness & distension
• 25% result in perforation
• precipitants may include:
  • use of anti-diarrhoeal agents
  • vigorous use of cathartics/enemas or barium enema

• 50% occur in pts with fulminant disease without toxic megacolon
• 50% occur in pts with toxic megacolon

• 10% pts

• <1% of patients

• 15% pts
• tend to occur in 1st year of disease & correlate with severity

• risk related to severity & duration of disease esp. over last 10-15 years
• risk appears to be 1% per person per year if have pancolitis
• overall risk 11% after 26yrs

• if acute, non-fulminating disease:
  • colonoscopy (C/I in fulminating disease as risk of perforation) & evaluation of biopsies
• chronic disease:
  • barium enema no longer Ix of choice (C/I in fulminating disease as may cause toxic megacolon or perforation if toxic megacolon is present) but may show:
    • rigid, shortened colon with loss of haustrations & destruction of mucosal pattern ⇒ “hoselike” colon
• if acute, fulminating disease:
  • gentle sigmoidoscopy may be diagnostic as rectum always involved in UC but is indistinguishable from infectious causes
  • plain AXR & erect CXR to exclude:
    • toxic megacolon:
      • transverse colon dilated > 6cm (usually > 8cm)
      • islands of necrotic tissue or gas in the bowel wall may be seen
    • perforation:
      • free gas under diaphragm

• infectious colitis - Campylobacter, Shigella, enterohaemorrhagic E. coli, C. difficile (colitis_pseudomembranous)
• acute ameobiasis - can be difficult to detect in stool, so do serology too
• Crohn's disease - 20% of cases cannot de distinguished histologically or clinically from Crohn's
• in AIDS pts:
  • chronic diarrhoea & diffuse colonic involvement of Kaposi's sarcoma
• in elderly pts in particular:
  • diverticulitis
  • ischaemic colitis
  • radiation colitis
  • carcinoma of colon

• admit any new patient suspected of acute UC for Ix and initial control of disease if confirmed:
• Ix:
  • gentle sigmoidoscopy
  • U&E, FBE, ESR, stool m/c/s ('hot' stool for amoebiasis), serology for amoebiasis
  • AXR, erect CXR
• Mx in ED:
  • inform surgeons/gastro. unit
  • if severe disease then 5 day regime:
    • nil orally
    • IV maintenance fluids
    • twice daily physical examination - inform surgeons of progress
    • record stool frequency & character as well as TPR,BP
    • daily: FBE, U&E, plain XRs, abdo. girth
    • IV hydrocortisone 100mg 6h (reduce dose after a week according to response)
    • hydrocortisone acetate foam enema 125mg x ii/day (reduce after a week prn)
    • IM vitamins
    • consider need for TPN
  • AVOID anti-diarrhoeals (may cause toxic megacolon)
• indications for proctocolectomy & ileostomy (total surgical mortality 2-7%):
  • deteriorating colitis after 5 days
  • toxic megacolon
  • perforation
• less severely ill:
  • steroids po / PR
• maintaining remission:
  • 5-amino-salicylic acid Rx either:
    • sulphasalazine 1g bd po reduces relapse rate by 65%
      • SE: rash, infertility
    • mesalazine 400-800mg tds po is s effective as sulphasalazine but without the sulphonamide side effects

steroids prn

• azathioprine for 6months may reduce need for steroids
  • monitor FBE
• carcinoma surveillance:
• 1-2yrly colonoscopy (more frequent if high grade dysplasia)
• if known UC with mild exacerbations or isolated proctitis then can be Mx as outpatients

• poor if early severe illness or extensive disease