32years with nearly 5 years history of confirmed ulcerative colitis(pan colitis) who is on pentosa,mesalamine ,steroids and other supportive measures presented with daily rectal bleeding ,loss of weight of over 20kgs,feverish feeling but no fever.His quality of life is getting affected.Azathiaprine has not yet tried.Seeks a remedy for this.would you suggest pursuing medical management or Total colectomy with Ileo-Anal pouch?
First exclude CMV and C. difficile or other infections. If negative since patient is young, one can try infliximab or cyclosporine followed by AZP before going for surgery. But all depends on the clinical scenario and response. Since history is short, malignancy is unlikely
1. you need to stage his colitis - is it severe ? moderate? - staging is important to further management - clinical staging (Trulove Witts), endoscopic staging (Mayo or UCEIS).
2. if the patient has severe colitis, he needs hospitalization, iv steroids, enteral nutrition, sometimes antibiotics iv, if it fails after 3-5 days there is a seroous argument for colectomy or antiTNF or cyclosprin iv
3. if colitis is moderate there is room for azatioprine therapy since it takes weeks to months for this treatment to have an effect
4. important thing is to rule out other etiology of colitis - bacterial infection, parasites, CMV colitis, drugs, cancer .....
Dear Dr. Reddy
From what it seems, this patient with pancolitis is having a severe flare of his colitis.
As usual, anytime a patient presents with a flare, you will need infectious causes as the underlying reason precipitating the flare. Once that is ruled out (CMV in the setting of steroids, C diff infection), you will then need to assess if he is compliant with the therapy. If the patient is very sick (as your patient seems to be), I prefer that he gets hospitalized, do abdominal imaging to make sure that he has is not developing toxic megacolon.
If he is already on steroids and continues to do poorly, I have found Infliximab to be the fastest way to induce remission. If however you can control his disease activity acutely via IV steroids, then you can offer him a choice of either Azathioprine or IFX or Adalimumab. In case you opt for AZA, within 8 to 12 weeks you would be able to tell if he is or is not responding. If he has NO response in 8 weeks on AZA, then I would switch to antiTNF therapy.
I think your patient is classified as a trulove moderate to severe colitis. I suggest a new endoscopic approach to confirm disease activity, try exclude infections (CMV, C difficile, paracytes). Make sure he does not use NSAIDS or aspirin as painkillers. As your patient does not respond to therapy with steroids and is Tuberculosis free, the only rapid available treatment to avoid operation is inflixibab -golimumab if available. Possibility to respond is 50%. Monotherapy might not be enough so if he responds you may add azathioprine. Serial quantitative CRP is of value
Always try azathioprine or mercaptopurine before colectomy. If your situation allows, try infliximab in azathioprine failure or intolerance. Never resort to colectomy too soon: it is NOT THE CURE. Anyone who is not a surgeon and follows postcolectomy patients will tell you that.
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