Tuesday, 3 December 2013

Fulminant colitis - Treatments in Conventional medicine

Colitis is defined as a condition of inflammation of the large intestine, including the colon, caecum and rectum.
A. In conventional medicine perspective
Fulminant colitis
A.7.1. Non surgical therapy
1. Immunosuppressive drug 
a.  Tacrolimus (FK-506)
Immunosuppressive drugs are increasingly being used as a therapeutic alternative to colectomy in patients with ulcerative or Crohn's colitis. According to the study of Tacrolimus (FK-506) Treatment of Fulminant Colitis in a Child in Journal of Pediatric Gastroenterology & Nutrition:October 1996 - Volume 23 - Issue 3 - pp 329-333, oral tacrolimus offers a potential alternative to cyclosporine in patients with steroid-resistant fulminant colitis and offers the potential advantages of more reliable oral absorption and greater ease of administration. The side effects of tacrolimus are similar to those of cyclosporine, but some adverse effects (including hypertension, gingival hyperplasia, and coarsening of facial features)(112).

b. Cyclosporine 
The use of immunosuppressive medications such as 6-mercaptopurine in individuals with fulminant disease is often limited by its very slow onset of action, unfortunately.  According to the study by Hartford Hospital, there is cases of two adolescents with fulminant colitis who were being considered for colectomy and who were treated with oral cyclosporine. Each appeared to have a prompt response to this medication, and both entered into a complete clinical remission. A mild increase in serum creatinine and hirsutism were the only side effects noted(113).

2. Other medicines
According to the study by Hahnemann University School of Medicine, patients with fulminant disease may require intravenous steroids and antibiotic therapy. If frequent relapses prevent discontinuation or significant reduction of prednisone therapy, azathioprine or 6-mercaptopurine may offer benefit as steroid-sparing agents. Also, intravenous cyclosporine has proved useful in patients with fulminant inflammatory bowel disease that is unresponsive to other therapy(114).

A.7.2. Surgical treatment
1. Total colectomy
Although total abdominal colectomy has long been considered definitive treatment for fulminant ulcerative colitis refractory to medical management, the optimal timing of surgery remains controversial. According to the study by The Mount Sinai Medical Center, showed that prolonged duration of preoperative medical treatment correlates with poor postoperative outcomes after total abdominal colectomy for fulminant ulcerative colitis. In addition, sustaining postoperative complications did not prevent patients from eventually undergoing IPAA(115).
Also in the study to to define clinical and radiographic variables associated with postoperative mortality after urgent colectomy for fulminant Clostridium difficile colitis with data obtained regarding patients undergoing colectomy for fulminant C. difficile colitis at two institutions (1997-2005), showed that
hirty-five patients (mean age 70 years, 46% male) underwent urgent colectomy for C. difficile colitis. The 30-day mortality rate was 45.7 per cent (16/35). The only clinical variable associated with mortality was preoperative multisystem organ failure (nonsurvivors 9/16 vs survivors: 4/19; P = 0.037). None of the three patients undergoing partial colectomy survived, although the difference in survival versus those undergoing subtotal colectomy was not significant. Patients with fulminant C. difficile colitis undergoing colectomy have a high mortality rate. Preoperative presence of multisystem organ failure was independently predictive of mortality(116).

2. Laparoscopic creation of an ileostomy
Due to several recent studies have elucidated factors that contribute to the unacceptably high postoperative mortality rate of colectomy, an alternative surgical strategy for fulminant C. difficile colitis is laparoscopic creation of an ileostomy with total colonic washout(117).
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(112) http://journals.lww.com/jpgn/fulltext/1996/10000/tacrolimus__fk_506__treatment_of_fulminant_colitis.23.aspx 
(113) http://www.ncbi.nlm.nih.gov/pubmed/2614627 
(114) http://www.ncbi.nlm.nih.gov/pubmed/7762487
(115) http://www.ncbi.nlm.nih.gov/pubmed/23062652
(116) http://www.ncbi.nlm.nih.gov/pubmed/20420254
(117) http://www.ncbi.nlm.nih.gov/pubmed/20583866 

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