Title: ACUTE SEVERE COLITIS, IN-PATIENT Ref: 1252 Version 1

INVESTIGATION, MONITORING AND MANAGEMENT

OF
Classification: Guideline
Directorate: General Medicine
Due for Review: 24/03/12
Responsible Document Control
for review: Dr Cathryn Edwards, Consultant Gastroenterologist

Ratified by: Dr K George, Consultant Gastroenterologist

Paul Foster, Clinical Director of Pharmacy

Applicability: All patients

Truelove and Witt’s Criteria define severe Ulcerative Colitis

Bowels open > 6 times per 24 hours

Plus any one or more of the systemic manifestations
• Haemoglobin < 10.5
• ESR > 30
• Pulse rate > 90
• Temperature > 37.5

The differential diagnosis includes bacterial infection (C. diff, Campylobacter, Salmonella, Shigella, E. coli
0157), viral infection if immuno-compromised (CMV), amoeba especially if travel history, Crohn’s colitis and
ischaemia. Diverticulitis can occasionally mimic. As ESR is not commonly used in this hospital, an elevated
CRP is usually taken as a positive criterion.

Monitor/record DAILY

• Temperature and pulse – 6-hourly

• Stool chart
• Frequency
• Colour / blood content
• Estimate of volume (record even if only passed blood or mucus)

• Abdominal examination findings: tenderness, bowel sounds

Note increasing pulse/temperature/abdominal pain or tenderness may indicate deterioration or frank

perforation and requires appropriate urgent investigation and d/w consultant.

Investigations

The aim is to confirm the diagnosis, assess severity and extent of disease, and identify / predict complications
early.

• On admission

• Stool culture + C. diff a minimum of 3 stool cultures: the first on admission the second 24 hours
later :THIS IS VITAL.

• It is likely that a limited lower GI endoscopy will be requested within 24-72 hours by a
Consultant Gastroenterologist or Surgeon. Referral to the Gastroenterologist of the day must be
Collated by Clinical Effectiveness Acute Severe Colitis, In-patient investigation, monitoring and management of
Page 1 of 6
 made immediately on Admission during the working week. Admission on the weekend should
result in immediate referral to the Gastroenterologist of the Day on Monday morning with strict
adherence to these guidelines meantime. If the patient is severely unwell during the weekend
with toxic dilation of the colon, the on call surgeon must be informed immediately. Request
urgent histology (state if patient immuno-compromised) to be analysied within 2 working days.

• Bloods
FBC CRP
ESR Mg
U&E, creat Cholesterol
LFT (albumin) (Blood cultures if temp > 38°)
Glucose

• Abdominal X-ray: look for stool-free colon (indicates extent involved); severe disease indicated by
mucosal oedema (thickened wall), mucosal islands, dilated small bowel loops, colonic dilatation
(diameter > 6cm)

• Daily (unless consultant requests otherwise)

• Bloods
FBC
U&E, creat (partic watch the potassium)
LFT
CRP (a vital prognostic guide)

• Abdominal X-ray for severe extensive colitis (any of fever, tachycardia, tenderness, dilatation on
initial films) – in absence of these criteria less frequent AXR is OK

Results must be reviewed the same day (especially potassium, particularly if abdominal X-ray is requested.

Management

• Approximately 25 – 30% of patients admitted with this condition will come to colectomy during the same
admission. The colorectal surgical team should thus be informed of all patients admitted with acute
severe colitis within 24 hours; any patient admitted with acute colitis who is not settling by day 3 should
be reviewed by colorectal team. It is vital that surgeons, stomatherapy etc are involved to give sufficient
time for planning and also allow the patient to come to terms with possible / probable colectomy.

• Malnourished patients should be considered for early calorie supplementation, either orally, naso-
gastrically or, if surgery is very likely, parenterally. They should be weighed and reviewed by the
dietician. Patients with severe disease are often nauseated and anorectic for the first day or two. If unwell
IV fluids and sips only for 24 hours or polymeric diet for first 24-48 hours (enlive ensure etc x6 cartons
per day).

• IV fluids to correct dehydration, with at least 60 mmol potassium per day

Patients are highly prone to hypokalaemia due to the diarrhoea and steroid therapy and this requires
close attention – particularly if anaesthesia for colectomy is imminent.

• Low molecular weight heparin – deltaparin 5,000 s/c od for all patients admitted for IBD regardless of
whether mobile or not. Acute IBD greatly predisposes to venous thrombosis – young people die with
thromboembolic complications of disease. National audit median only 62% of patients got prophylactic
heparin. Torbay’s result 74%(Nat Audit): 67% in house audit.

• Antibiotics, IV metronidazole 500 mg tds, + a broad spectrum antibiotic such as Tazozin should be used if
perforation suspected (discuss with consultant) or in febrile patients (temperature > 37.8) who have

Acute Severe Colitis, In-patient investigation monitoring, and management of Collated by Clinical Effectiveness
Page 2 of 6
 toxic dilatation on AXR. Stool and blood cultures must be sent first. Oral Metronidazole or vancomuycin
should be used if CDT suspected (discuss with consultant). For UC in the absence of these features
antibiotics are not routinely indicated.

• Oral 5-ASA can be withheld while on intravenous therapy (there is no evidence that they have a role in
acute severe colitis), but restart this on discharge or if therapeutic heparin is used (see below).

• Avoid anti-diarrhoeals, opiates etc., and avoid NSAIDs if at all possible. If the patient is experiencing
severe pain d/w consultant.

• The steroid regime is IV hydrocortisone 100 mg qds + rectal hydrocortisone 100 mg in 100 ml normal
saline bd given by soft rectal cannula (Foley catheter) over 30 minutes via IV giving set.

• Look for and treat proximal constipation if present in distal disease: often requires ½ - 1 sachet picolax,
followed by regular Magnesium hydroxide.

Of patients presenting with acute severe colitis, 50% will make a good response to the above regime, 25% will
require colectomy, and 25% will make a partial response, requiring careful assessment and discussion re
increased immunosuppression vs surgery.

Of the patients who are failing to respond the options lie between ciclosporin, infliximab or colectomy.
After three days on intravenous steroids in the context of severe colitis with systemic manifestations as
defined above, the presence of

Either

• Stool frequency > 8 times per 24 hours

or
• Stool frequency > 3 times + CRP > 45

gives an 85% likelihood of requiring colectomy (ref Travis). For patients with resistant proctitis these criteria
do not generally apply.

Ciclosporin regime
Oral ciclosporin can be added in those not responding to or intolerant of steroid therapy provided a minimum
of 2 sets of stool cultures have been negative. This is a consultant decision See ciclosporin guidance sheet. .
For some patients we use oral ciclosporin as it is well absorbed and logistically easier. The starting dose is
5mg/kg/24 hrs divided into a BD regimen. Check pre-dose levels after 36-48 hours (in practical terms check
blood before morning tablets due, then give the tablets without waiting for result and adjust subsequent doses
if necessary to acheive drug level of 150-250 mcg/l).

Septrin 960mg alt days should be given as prophylaxis against opportunistic infection.

Patients for IV ciclosporin should be warned of the slight risk of seizures. IV preparation should be avoided if
cholesterol is < 3 (oral ciclosporin can be used in this situation) or Mg is <1.5 (add iv Mg to fluid regime). IV
ciclosporin should be used at a dose of 2 mg/kg per 24 hours given in 250 ml normal saline over 24 hours.
Check levels after 36-48 hours, and adjust the dose if necessary to achive drug level of 150-250 mcg/l.

Approximately 50% will respond to ciclosporin, of whom 50% will relapse when ciclosporin is stopped. Even
in relapsers the time ‘bought’ can be useful to allow adjustment to the idea of colectomy and its implications.

Collated by Clinical Effectiveness Acute Severe Colitis, In-patient investigation, monitoring and management of
Page 3 of 6
Infliximab

This is given as a single rescue infusion once x2 (minimum) stools are negative hep B and C checked and
bloods taken for baseline ANA and ds DNA performed (audit issue). Patients will if responding switch to oral
prednisolone (see below) and AZATHIOPRINE started or dose increase as appropriate.
These are consultant led decisions.

The Janerot paper suggests 70% early remission. Work from Edinburgh shows albumen is good predictor of
response; an albumen of 30 or less indicates a poor outcome but this is really only selecting out the sicker
patients ie those who are likely to need surgery anyway.

Thereafter
If improvement is seen all treatments should be switched to oral on Day 5-7.

• Oral prednisolone 40 mg od one week, 30 mg od one week, thereafter weaning by 5 mg per week (or 40
mg od one week, 30 mg od one week 20mg for 4 weeks then reduce by 5mg a week)

• Oral 5-ASA

• Oral diet which should be low fibre ( and in some patients low lactose)

• Oral AZATHIOPRINE should either be continued or dose increased. Interaction with 5ASA should be
remembered (all patients newly starting AZATHIOPRINE or 6 MP should have their TPMT levels
checked)

• Oral ciclosporin (“Neoral”) 5 mg/kg per day. Check level at one week (aim 150 – 250 mcg/l). Should aim
to wean over to azathioprine after 6-8 weeks, once the prednisolone has stopped or is at least at low dose
(below 15 mg/d). Vigilance is required for opportunistic infection: use of PCP prophylaxis with Septrin
960mg alt days (avoid in pregnancy) in those on high dose immunosuppression (ie ciclosporin and either
prednisolone or azathioprine). (For CONSTRUCT trough levels of 100-200 nanograms per ml is target
see protocol)

This may “make or break” those with an incomplete response to intravenous therapy – ie stool freq > 3x/day,
persistent rectal bleeding. If symptoms increase at this point then surgery is usually indicated; a further course
of iv steroids rarely helps and makes subsequent surgery hazardous.

Patients should be reviewed two weeks after discharge in the out-patient clinic.

Indications for colectomy

• Toxic dilatation of the colon: if present on admission, 24-48 hours of intensive medical therapy is
warranted provided the patient is sufficiently stable. Failure to respond by 48 hours, or the development of
dilatation during medical therapy mandates colectomy.
• Perforation
• Massive bleed
• All patients who are failing to improve on Day 3 should be discussed with the colorectal surgeons such
that the patient is monitored closely by both medical and surgical teams and if colectomy is required this
happens in a planned manner on or soon after day 5. Stoma Therapy, etc will then have had a chance to
review the patient, provide explanation and information etc. Few patients who have not made a good
response to medical therapy by day 5-7 will subsequently respond, and the risks of surgery escalate with
increasing delay
• Deterioration at any stage during admission may also necessitate urgent colectomy.

Acute Severe Colitis, In-patient investigation monitoring, and management of Collated by Clinical Effectiveness
Page 4 of 6
 Care Pathway for Management of Acute Severe Colitis
Addressograph Date of admission: _/_ /_
Previous Δ: UC / Crohn’s / indeter / nil
Length of flare: wks
Mandatory observations / investigations:
Day 1 Day 3 Day 5 Day 7

Temp

Bowels/24 hrs

Pulse

ESR

CRP

Albumin

Hb

Plts

Stool culture Sent: 1) _/_ 2) _/_ 3) _ / _ (date sent)

Result: 1) 2) 3)
Stool chart started: _/_
Sigmoidoscopy: _/_ Macroscopic:
Microscopic:
AXR: 1) _ / _ 2) _ / _ 3) _ / _
Treatment
• iv steroids: _/_
• rectal steroids
• deltaparin
• antibiotics (Crohn’s or toxic UC)
• Ciclosporin: _/_ pre-dose level ---------------
• Infliximab
• Bone Prophylaxis

Management
IBD Nurse Referral: review
Dietician referral: review Weight on admission .. discharge..
Surgical referral: _/_ Colectomy: _/_

Collated by Clinical Effectiveness Acute Severe Colitis, In-patient investigation, monitoring and management of
Page 5 of 6
Protocols & Guidelines – Document Information
This is a controlled document. It should not be altered in any way without the express permission of the
author or their representative. On receipt of a new version, please destroy all previous versions.

Title: Acute Severe Colitis, In-patient investigation, monitoring and

Ref: 1252
management of

Date of Issue: 24 March 2010 Next Review Date: 24 March 2012

Version: 1
Author: Dr Cathryn Edwards, Consultant Gastroenterologist
Index: General Medicine
Classification: Guideline
Applicability: All patients
The guidance contained in this document is intended to be inclusive for all
Equality Impact: patients within the clinical group specified, regardless of age, disability, gender,
gender identity, sexual orientation, race and ethnicity & religion or belief.
Evidence based: Yes
Truelove and Witt’s criteria
References:
Travis
Produced following audit: No
Audited: No
Approval Route: See ratification Date Approved: 17 March 2010
Approved By: Dr K George, Consultant Gastroenterologist
Paul Foster, Clinical Director of Pharmacy
Links or overlaps with other policies:
All SDHCF Trust strategies, policies and procedure documents.

RATIFICATION:

PUBLICATION HISTORY:

Issue Date Status Authorised

1 24 March 2010 New Dr K George, Consultant Gastroenterologist
Paul Foster, Clinical Director of Pharmacy

Acute Severe Colitis, In-patient investigation monitoring, and management of Collated by Clinical Effectiveness
Page 6 of 6