A 30-year-old woman with ulcerative colitis treated with mesalamine is hospitalized for nausea, abdominal pain, and diarrhea. She has had 8-10 bloody bowel movements every day for the past week with associated tenesmus, anorexia, and a 2-kg (4.4-lb) weight loss. The patient reports no recent travel, antibiotic use, or eating anything unusual. She does not use tobacco, alcohol, or illicit drugs.
Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 92/min, and respirations are 16/min. Examination shows a mildly distended abdomen. There is mild diffuse tenderness but no involuntary guarding or rebound tenderness. Bowel sounds are present in all quadrants. Stool is positive for occult blood.
Laboratory results are as follows:
Abdominal and upright chest radiographs are unremarkable with no free air or severe colonic dilatation. Stool testing for Clostridium difficile is negative and stool cultures are sent.
Which of the following is the most appropriate next step in management of this patient?

Question

A 30-year-old woman with ulcerative colitis treated with mesalamine is hospitalized for nausea, abdominal pain, and diarrhea.  She has had 8-10 bloody bowel movements every day for the past week with associated tenesmus, anorexia, and a 2-kg (4.4-lb) weight loss.  The patient reports no recent travel, antibiotic use, or eating anything unusual.  She does not use tobacco, alcohol, or illicit drugs.
Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 92/min, and respirations are 16/min.  Examination shows a mildly distended abdomen.  There is mild diffuse tenderness but no involuntary guarding or rebound tenderness.  Bowel sounds are present in all quadrants.  Stool is positive for occult blood.
Laboratory results are as follows:
 Abdominal and upright chest radiographs are unremarkable with no free air or severe colonic dilatation.  Stool testing for Clostridium difficile is negative and stool cultures are sent.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_96cd_a5b5_853d_81719fdadbdc_MD0002_00 This patient has an acute severe ulcerative colitis (UC) flare, characterized by >6 bloody bowel movements per day, severe abdominal cramps, weight loss, tachycardia, fever, anemia, and elevated inflammatory markers (eg, erythrocyte sedimentation rate). The initial evaluation should include stool studies to rule out infectious colitis (culture, ova, and parasite; Clostridium difficile toxin), flexible sigmoidoscopy to evaluate the extent of disease, and examination for signs of toxic megacolon or colonic perforation. Management of a severe UC flare includes systemic glucocorticoids and high-dose 5-aminosalicylic acid (5-ASA) compounds. Treatment should not be withheld while awaiting the results of stool studies due to the risk of developing toxic megacolon. Empiric antibiotics (ciprofloxacin/metronidazole) are recommended in severe UC flares only if the patient has signs of severe systemic toxicity (high fevers, marked leukocytosis with left shift and bandemia), evidence of toxic megacolon, or peritonitis (Choice D). Patients are assessed for response to treatment after 3-5 days. Those with a complete response can transition to oral corticosteroids, but those who fail to respond after 7-10 days of therapy are considered steroid refractory and require either cyclosporine or a tumor necrosis factor inhibitor (eg, infliximab) (Choice A). Those who remain refractory usually require colectomy. (Choice B) Colonoscopy is avoided during a severe ulcerative colitis flare due to the increased risk of toxic megacolon. (Choice C) Abdominal CT scan is useful for evaluation of toxic megacolon or perforation, but is not indicated in this patient as physical examination and x-rays are unremarkable. In addition, CT scans should be limited in UC patients due to the cumulative lifetime radiation dose from frequent scans. Educational objective: Severe ulcerative colitis flare is characterized by >6 bloody bowel movements per day, tachycardia, anemia, fever, severe cramps, weight loss, and elevated inflammatory markers. Treatment includes systemic glucocorticoids and high-dose 5-aminosalicylic acid compounds. Treatment should not be withheld while awaiting test results due to the risk of developing toxic megacolon. __________ References: Review article: the optimal medical management of acute severe ulcerative colitis. (http://www.ncbi.nlm.nih.gov/pubmed/20626381)

A 30-Year-Old Woman with Ulcerative Colitis Treated with Mesalamine Is