Diarrhea- UC flare

Question

77M presents to the emergency department with a 3/52 history of bloody diarrhoea and abdominal pain. On further questioning, he is opening his bowel between 8-10 times/day.

Answer

The general structure of the answer is similar to the previous scenarios.

He has a past medical history of Ulcerative colitis (for which he takes Mesalazine) and HTN (taking Amlodipine). His last colonoscopy 2 years ago showed mild left-sided colitis and proctitis.

Examination

• HR: 98/min
• T: 37.6
• BP: 122/77
• RR: 20/min
• Sats: 98% (air)
• Abdomen: soft, but generalised tenderness. Bowel sounds present.
• Chest and CVS: NAD

Bloods

• CRP: 67
• WCC: 12
• Hb: 98
• MCV: 77
• Plt: 430
• Ferritin: 631
• Albumin: 28
• Otherwise normal renal and liver profile

Impression and Management

Acute severe flare of UC (according to Truelove and Whitts classification)

1. This patient needs hospital admission. Mortality and colectomy rate for these patients remain high.
2. A to E assessment. Airway and breathing are likely fine. These patients tend to be unwell and dehydrated and may need IV fluids and electrolytes to mitigate losses.
3. Definitive treatment: IV hydrocortisone 100mg 6 hourly.
4. AXR to rule out toxic megacolon. Can consider CT abdomen pelvis if there are concerns about perforation (significant abdominal pain component or inflammatory markers markedly elevated). If evidence of toxic megacolon – immediate surgical review is mandated.
5. Stool cultures to rule out infection/C. Diff.
6. Prebiologic screen in preparation for salvage therapy.
7. Unprepped flexible sigmoidoscopy and biopsies to look for extent and severity of colitis and to rule out CMV colitis.
8. Gastro review: These patients are best managed on a Gastro ward.
9. Daily review/daily bloods.
10. If after 3 days, still no response (CRP > 45, BO 4-8/day) – consider salvage with Infliximab or Ciclosporin (we rarely use Ciclosporin).
11. If 7-10 days – unchanged/worsening symptoms or complications such as perforation/toxic megacolon prior to this – surgical review and subtotal colectomy if candidate. These patients do worse when surgery is delayed, hence definitive plans and decision-making are important.