Pearls from Dr. Suneeta Krishnareddy
Differential of Bloody Diarrhea
- Shiga toxin producing E. coli (EHEC), E. coli O157:H7
- IBD Flare
Posted 10/25/16 09:03:05 AM by Ying Liu
Indicators of UC Disease Severity (Truelove Witts Table)
- Number of stools per day
- Temperature, HR, Clinical signs (abdominal pain)
- Elevated ESR/CRP
- Radiographic imaging showing bowel edema/dilation
- Extra-intestinal Markers of Disease that increase with flare include uveitis (not iritis), big joint disease (not small or AS), Erythema Nodosum (not pyoderma)
Posted 10/25/16 09:04:57 AM by Ying Liu
Infection in UC
- High rates of C. Diff given mucosal breakdown; can also precipitate IBD flare
- C. Diff Stool PCR has high sensitivity (90%) and Specificity (96%) and good PPV and NPV
- Treat empirically with PO Vancomycin, metronidazole has less utility
- Also cover empirically with Cipro/Flagyl
Posted 10/25/16 09:07:54 AM by Ying Liu
Induction Therapy for Severe/Fulminant UC (in addition to steroids)
- First-line is Infliximab (5-10mg/kg) at 0,2, and 6 weeks then maintenance therapy
- 2nd-line is Cyclosporine A but Cochrane review is equivocal and no good bridge therapy after induction
- Vedolizumab (integrin inhibitor, blocks leukocyte trafficking into GI mucosa) is a possibility but only approved for moderate disease
Posted 10/25/16 09:11:21 AM by Ying Liu
Indications for Colectomy
- Colonic Perforation
- Massive GI bleeding
- Toxic Megacolon
- Acute Fulminant Colitis refractory to medical treatment
NOTE: Would scope and biopsy prior to surgery to confirm diagnosis as preferred surgery for UC is J-pouch to preserve rectal function, but this surgery is terrible for Crohn's. This is one instance where serologies have utility.
Posted 10/25/16 09:13:59 AM by Ying Liu
- UC associated with PBC; can pick this up with elevated alkphos but not in acute setting
- Proctitis does not affect CRC risk
- Currently, no genetic screening recommendations for UC
Posted 10/25/16 09:14:59 AM by Ying Liu
Posted 02/14/17 05:45:28 PM by Adam Faye
- 5-ASA appropriate for UC patients (some data suggests decreases colorectal cancer risk). Does not work for Crohn's disease.
- CRC risk in UC: 1.0% by 10 years, up to 2.0% by 15 years, and 1.1%–5.3% by 20 years.
Budesonide will not work in UC because it acts in small intestine, not in the colon. There is a formulation that works in the colon but very expensive.
Posted 02/14/17 05:47:38 PM by Adam Faye
- Seems to be safe in traveler's diarrhea (not in C. diff) - may even decrease length of time to formed stools
Posted 02/14/17 05:48:55 PM by Adam Faye
TNF therapy in UC:
- 239 Treatment naïve patients with moderate-severe UC followed for 16 weeks:
- Endpoint- steroid-free remission
- Corticosteroid free remission at week 16: 39.7% in infliximab/azathioprine vs. 22.1% in infliximab vs. 23.7% azathioprine alone
- Also had better mucosal healing; 62.8% vs. 54.6% vs. 36.8%
- Serious infections: 1 in azathioprine group and 1 in infliximab group
Posted 02/14/17 05:56:17 PM by Adam Faye
- 47.1% vs. 25.5% response by week 6 drug vs. placebo respectively
Patients who had a response by week 6 -> randomized to placebo or Vedolizumab every 4/8 weeks for up to 1 year.
- At 52 weeks:
- 41.8% who received drug every 8 weeks were in remission
- 44.8% who received drug every 4 weeks were in remission
- 15.9% for placebo
Posted 02/14/17 05:57:37 PM by Adam Faye
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