Fulminant Colitis

New Challenges

M62 Coloproctology course 2004

Issues

• Changing patterns of disease

• Developments in drug therapy

• Timing surgical intervention

• Surgical practice

Patterns of Disease IBD

• Rising incidence of Crohn’s disease

Copenhagen

– presentation

– investigation

Patterns of Disease IBD

• Rising incidence of Crohn’s disease

Copenhagen

– presentation

– investigation

Patterns of Disease

UC Crohn’s

Patterns of Disease non-IBD

• Clostridum difficile

• Vascular disease

• Immune-compromised

Pseudomembranous colitis

• Rising incidence 30-100%/10yrs• Recurrent attacks – 20%• Subtotal colectomy – 100% mortality

– Pre-op D – 46% Koss 2004

Dallal 2002

Morris 2002

Sharma 2003

Koss 2004

Source Nr Cases Cdiff

Severe Mort

Hosp 2300 64 60%

Hosp 157 51 20%

NOF 239 17 35%

Gastro 13 38%

Pseudomembranous colitis

• Immunosupression– Lung TT

• CT diagnosis

Cardiac Patients

• Major GI complications- high mortality• Surgical decisions - complex

– Cardiac surgery: scope: stool cultures

Centre Nrs GI Compl

C-

diff

Isc-aemia

Mort

Texas 11,000 147 18 17 22%

Frankf. 1,000 23 85%

Imuno-compromised patients

• Cytomegalovirus infection– Refractory colitis– 30% (16/47) infected– 8/12 responded to treatment Wada 2003

• Immunosuppressed IBD– 23/23 colitis– 0/10 CRC– 21/23 early a’gen +ve Rahbar 2003

• Mimics PMC Olfinlade 2001

Study of CMV/PMC in acute colitis required

Medical Managementdevelopments

• The Oxford criteria– the five day rule Truelove @ Jewell 1974

• Azathioprine– maintenance of remission

• Cyclosporin– induction of remission McCormack G 2002

VanAssche G 2003

Medical Managementchallenges

• Uncertain end points

• Masked sepsis

• Late relapse– immunosuppression

Mallant-Hent 2003

Surgical Issue

• UC - fragile colon

• Crohn’s - loss of planes

• Rectal stump(ed)

Surgical Issue

• UC - fragile colon

• Crohn’s - loss of planes

• Rectal stump(ed)

Surgical Developments

• One stage reconstruction– cyclosporin Hyde GM 2001

• Laparoscopy Hurley BW 2002

Marcello PW 2001

- interval procedure

• Reconstruction in Crohn’s disease?

New Challenges?

• Team management Truelove @ Jewell 1974

– MDM– Shared care– Mixed wards

Patterns of Disease non-IBD

• Broad spectrum antibiotics– pseudomembranous colitis

• Multisystem disease– ischaemic colitis

• Immune-compromised– viral infections– multifactorial disease

Clostridium Difficile

• 2,000 cases over 10 years

• 64 colectomies

• incidence rising– 0.6 - 1.2%

• life threatening cases also doubled – 3%

Dallal RM,Ann Surg. 2002