Ulcerative colitis (UC) is a chronic disease featuring recurrent inflammation of the colonic mucosa.

 

 

 

The goal: steroid-free remission while at the same time preventing complications of the disease itself.

The choice of treatment depends on severity, localization and the course of the disease.

Proctitis

For proctitis, topical therapy with 5-aminosalicylic acid (5-ASA) compounds is used.

More extensive or severe disease should be treated with oral and local 5-ASA compounds and corticosteroids to induce remission.

Patients who do not respond to this treatment require hospitalization. Intravenous steroids or, when refractory, calcineurin inhibitors (cyclosporine, tacrolimus), tumor necrosis factor-α antibodies (infliximab) or immunomodulators (azathioprine, 6-mercaptopurine) are then called for.

Indications for emergency surgery include refractory toxic megacolon, perforation, and continuous severe colorectal bleeding.1

Clinical Vignette

A 45-year-old man with a 15-year history of ulcerative colitis (UC) is evaluated in the outpatient office because of chronic bloody diarrhea over the past 6 weeks. The patient’s vital signs are normal. His hemoglobin level is 11.0 g/dL. His current medications consist of prednisone and mesalamine (a 5-aminosalicylate derivative), and he recently completed a course of cyclosporine therapy 2 months ago for another bout of disease flare-up. The patient has been unable to maintain full-time employment as an accountant over the past year because of UC exacerbations. Previous colonoscopy has shown that his disease extends from the rectum to the cecum.

Questions

What should be your next step?

What is the best therapy?

Answers to Case 27: Ulcerative Colitis

Summary: A 45-year-old man with pancolonic chronic UC that has become refractory to medical management and is causing him significant disability.

  • Next step: The option of surgical therapy should be presented to this patient. The discussion should explain the benefits, risks, and limitations of surgery versus those of continued medical therapy.

  • Best therapy: Proctocolectomy with ileal pouch-anal anastomosis.

 

 

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