THE MODERN MEDICAL-MANAGEMENT OF ACUTE, SEVERE ULCERATIVE-COLITIS

The management of patients with acute, severe ulcerative colitis requi res careful in-hospital assessment of the patient and the coordinated treatment of a team of experienced gastroenterologists and surgeons. C omplete understanding of the potential complications and their managem ent, especially toxic megacolon, is essential. We review the current m edical arsenal and advocate a standardized approach to management that includes continuous, high dose intravenous hydrocortisone, more aggre ssive use of topical steroids as well as feeding the patients and cont inuing (but not initiating) oral 5-aminosalicylic acid (5-ASA) agents. For those patients whose disease proves refractory to intravenous ste roids, intravenous cyclosporin (with an acute response rate of 82%) is an essential component in the medical management of these patients. A ntibiotics should be used only when specifically indicated. Total pare nteral nutrition has not been shown to be helpful in the acute setting . Air contrast barium enema and colonoscopy have been used to predict response but may be dangerous diagnostic modalities in these acutely i ll patients and are no better than good clinical judgement. We review and advocate long-term management of acute response using 6-mercaptopu rine or azathioprine. The surgical experience and the postoperative co mplications of the ileal pouch anal anastomosis, which include acute p ouchitis in 50-60%, chronic pouchitis in 5-10% and recent reports of d ysplasia among patients with chronic pouchitis, must be considered bef ore colectomy is advised. Over 80% of patients with acute severe colit is can be spared colectomy using our current arsenal of medical therap ies.