- Identify the key features of a presentation that help characterize the severity of an IBD flare
- Develop a stepwise approach to in-hospital escalation of UC therapy
- Discuss the different clinical manifestations between ulcerative colitis and crohn disease
A 33 year old man with a history of ulcerative colitis presents with 3 weeks of progressively worsening bloody diarrhea (now 8-10 times a day), abdominal cramping, tenesmus, rectal pain and a five pound unintentional weight loss. He denies fevers, chills, nausea, vomiting or skin changes. His ulcerative colitis was first diagnosed 2 years ago, staged as mild disease and has been well managed with oral mesalamine.
On exam he is afebrile, HR 110, BP 107/75, RR 20, SpO2 98%. He appears comfortable with a mildly tender abdomen throughout. No perianal fistula or palpable fluctuance on external anal exam. Labs are notable for Na 130, Cr 1.2, WBC 12k, Hct 29%, Plt 250, INR 1.1, nml LFTs, ESR 40, CRP 185.
What key clinical features of this patient’s history help stratify the severity of his IBD?
- Failing his current management, 5-ASA
- Greater than 6 bloody stools/day
- Evidence of systemic illness, including fever, tachycardia, weight loss and elevated inflammatory markers
Staging IBD is important for guiding management and determining prognosis. What tools or classification systems are available for Crohn disease (CD) and ulcerative colitis (UC)?
There are multiple scoring systems available. Some are based on symptoms, exam and labs (i.e. Montreal Classification or Crohn Disease Activity Index) while others incorporate imaging and endoscopic findings (i.e. Mayo Score for UC). Appropriately staging IBD and determining the right therapy is complex, especially as the disease becomes more advanced, refractory to multiple therapies and as more biologic agents become available. It relies on a combination of all the above features along with distribution of disease, IBD associated complications, insurance and a patient’s tolerance of therapy. Ultimately, the decision for appropriate therapy is highly specialized.
That being said, as a generalist evaluating a patient with an IBD flare, it is useful to identify those with severe disease and/or failing their current therapy. This will help determine necessity for admission, whether they need induction or re-induction with steroids and potential initiation of cyclosporine or biologics during the hospitalization. For this purpose, the Montreal Classification can be useful. It is a quick assessment based on the clinical features we already discussed (i.e. more or less than 4-6 stools/day and evidence of systemic illness?).
Let’s review some terminology and treatment options for severe UC by working through the following management pathway.
Teaching Instructions: Draw the pathway on the board with blanks in the spaces for the various treatments. Discuss the difference between induction and maintenance therapy. Then prompt the group to decide what they would do at various stages. Guide them in the right direction and compare to the answer diagram when done.
Given this patient’s clinical presentation, how would you manage him overnight, what work-up would you initiate and what do you anticipate will happen during his hospitalization?
- Collect stool sample for c.diff and enteric battery to r/o infection. Send hepatitis panel, IGRA TB screening and TPMT activity in anticipation for initiating biologics and/or azathioprine (AZA). Make NPO for possible colonoscopy (sometimes avoided for concern of precipitating toxic megacolon).
- Start IV steroids, IVF resuscitation, consider emperic abx (cipro/flagyl). After colonoscopy restart diet as tolerated and consider supplemental nutrition. Stop 5-ASA.
- If unresponsive to steroids after 7d, consider starting infliximab or cyclosporine + AZA
UC and CD have classically been described as separate disorders. However, they have significant overlap and there is increasing controversy as to whether they are simply different manifestations of the same disease and it may be more appropriate to describe them as IBD with certain distributions and complications (i.e. IBD of distal colon). What are some of the classic differences between the UC and CD?
In general terms, how does the above UC management pathway potentially differ from that of CD
- While colectomy is definitive management of UC, surgery is avoided unless absolutely necessary in CD given the potential of disease involvement anywhere from the mouth to anus.
- CD may be complicated by abscesses, fistulas, strictures and small bowel obstructions.
The patient was admitted to the medicine service for a severe crohn’s flare requiring induction therapy. His 5-ASA was discontinued and he was initiated on methylprednisalone 60mg IV daily. A colonoscopy on the following morning revealed pancolitis with friable mucosa and active bleeding. Testing for c.diff and other enteric pathogens was negative. His frequency of bowel movements improved to 3-4 non-bloody stools by hospital day 3. On day four his TPMT activity was still pending and he was discharged on an oral prednisone taper with plans for initiation of AZA with or without a TNF inhibitor in clinic a few weeks later.
TAKE HOME POINTS:
- Frequency of bloody vs. non-bloody stools, evidence of systemic disease (fever, leukocytosis, elevated ESR) and anemia are useful markers for determining severity of an IBD flare
- UC can be definitively managed with a colectomy while there is no definitive management for CD.
- Always test TPMT activity prior to initiating AZA given the heterogeneity in rates of metabolization and potential for toxicity.