| Invited Lecture(JSGE) |
| Thu. November 21st 11:30 - 12:00 Room 12: Kobe International Conference Center Main Hall |
| Common mistakes in the treatment of the hospitalized patient with UC | |||
| Corey Siegel | |||
| Dartmouth-Hitchcock Medical Center | |||
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| The most severe patients with ulcerative colitis are those with acute severe ulcerative colitis (ASUC), and these patients are typically hospitalized for emergent care. Hospitalized patients with UC represent a very sick group of people and mistakes in their care can lead to devastating results, including significant morbidity and mortality. First, is it important to make sure that you are treating the right disease, as other things can mimic a flare. An investigation for infection is crucial, specifically for C. difficile infection and cytomegalovirus (CMV). In older patients and those with risk factors for vascular disease, ischemia should also be considered in the differential diagnosis. A sigmoidoscopy (no prep needed) should be performed within 24 hours of hospital admission to make sure that a flare of ulcerative colitis is the only process that needs to be treated. A common mistake is waiting too long for appropriate therapy. Even if colectomy is not planned or desirable, a surgeon should meet the patient soon after admission to be part of their care and decision making. It is always better for patients to meet a surgeon before surgery becomes an emergency. Corticosteroids are typically started intravenously at admission. If a patient has not had significant improvement 72 hours after admission, second line therapy should be considered and planned. Waiting longer than seven days on IV steroids offers no further benefit and may increase the risk of complications for the patient. When rescue therapy is started, it is common to under dose the patient. With a severe inflammatory state, higher doses of biologic drugs are necessary to improve the chance of response. For infliximab, many start with 10mg/kg as the first dose, or give a second dose of 5mg/mg within a few days of the first 5mg/kg dose. If patients are not improving after second line therapy is delivered with appropriate dosing, surgery should be strongly considered. It is critical to deliver prophylaxis for deep vein thrombosis (DVT), and to watch out for opportunistic infections such as pneumocystis jiroveci pneumonia (PJP). Furthermore, there is no role for fasting the patient, and proper nutrition is important for both hydration and nourishment. Discharge of the patient should only occur after marked clinical improvement and the ability to take outpatient medications with proper oral hydration and nutrition. |
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