Optimal management of acute severe ulcerative colitis in children / 中华实用儿科临床杂志

Acute severe ulcerative colitis (ASUC) is one emergency in pediatric gastroenterology.The disease is serious, which may even endanger the life of patients.Close monitoring and timely pharmacological and surgical interventions are key measures to improve outcomes.Treatment methods for ASUC include necessary nutritional support, water and electrolyte disturbance correction, and possible concurrent bacterial or viral infection elimination.Patients at high risk require subcutaneous injections of low molecular weight heparin to prevent thrombosis.Intravenous cortico-steroids are the first-line treatment of ASUC.For patients showing insufficient response to corticosteroids after 3-5 days, rescue treatment with immunosuppressants or biological agents is needed.Meanwhile, the clinical symptoms, serum inflammatory indicators and albumin levels of the patients should be closely monitored.Patients who failed medical treatment should undergo timely colectomy to prevent serious complications.In this paper, a systematic review of literature and expert consensus was conducted to summarize the clinical evaluation and treatment methods of ASUC children at different stages, in order to standardize the clinical treatment of pediatric ASUC.

Management of Acute Severe Ulcerative Colitis / 胃肠病学

Acute severe ulcerative colitis (ASUC) is a medical emergency that requires prompt diagnosis and treatment. Intravenous corticosteroids are the first-line medical therapy, yet over 30% of the patients are steroid-refractory. The response to steroids should be assessed on day 3 after treatment initiation; in non-responders, treatment options including ciclosporin and infliximab, or surgery should be considered. Both ciclosporin and infliximab are effective and safe salvage therapy. Colectomy is recommended if there is no improvement following 4 to 7 days of salvage therapy. Total proctocolectomy and ileal pouch-anal anastomosis is the standard surgical procedure. A three-step approach is advocated and the postoperative complications should be cared. The diagnosis and treatment of ASUC requires multidisciplinary cooperation in order to improve prognosis and reduce mortality.

Therapeutic Response to Glucocorticoids and Predictive Factors in Severe Ulcerative Colitis / 胃肠病学

Background: Intravenous glucocorticoids (GCs) are the first-line therapy of severe ulcerative colitis (SUC), however, part of the SUC patients are steroids-refractory. Aims: To investigate the predictive factors of therapeutic response to GCs and whether prolonging GCs therapy is beneficial for patients with SUC. Methods: Data of patients with SUC admitted in Anhui Provincial Hospital from Jan. 2006 to Dec. 2017 were collected consecutively. Patients were categorized into different groups according to the responsiveness to intensive intravenous GCs therapy on day 7 and day 14 (in prolonged treatment group), and their general conditions, clinical, laboratory, endoscopic, pathological features and outcomes were compared and analyzed for finding the predictive factors. Results: Complete remission and partial remission was achieved on day 7 in 20 (22.7%) and 43 (48.9%) of the 88 SUC patients, respectively, and the other 25 cases (28.4%) were non-responders. Univariate analysis revealed that defecation >10 times on admission, >6 times on day 3, bloody stool on day 3, pancolitis, and abnormal laboratory findings including ESR and albumin (ALB) on admission, and CRP and CRP/ALB ratio on admission and on day 3, were associated with poor response to GCs (P40 mm/h on admission and defecation >6 times on day 3 were the independent risk factors for treatment failure of GCs (P40 mm/h on admission and defecation >6 times on day 3 might be the independent predictors for poor response to GCs in patients with SUC. A small part of SUC patients with partial remission on day 7 can achieve complete remission by prolonged (14-day) GCs therapy.

Operation timing of severe ulcerative colitis / 中华消化外科杂志

Acute severe ulcerative colitis (ASUC) is a potentially life-threatening condition.Inappropriate salvage therapy might delay the surgery and increase the mortality and postoperative complications in ulcerative colitis (UC).Timely surgical intervention for UC is the key to reduce the rate of mortality and postoperative complications via evaluating the effect of therapy combining with characters of patients' history,clinical symptoms,biochemical markers,radiological and endoscopic criteria.

Efficacy of Infliximab as Rescue Therapy in Acute Severe Ulcerative Colitis / 胃肠病学

Background:Of patients with acute severe ulcerative colitis (ASUC),30% -40% is steroid-refractory and required second-line medical therapy or colectomy. Infliximab (IFX)may be effective as rescue therapy. Aims:To explore preliminarily the efficacy and safety of IFX as rescue therapy in ASUC in China. Methods:A retrospective study was conducted in 10 consecutive ASUC patients receiving IFX as rescue therapy from June 2012 to September 2016 at Peking Union Medical College Hospital. The modified Mayo score and laboratory parameters were compared at baseline and on week 2,week 12 and week 30 of the treatment course. Results:The response rates on week 2,week 12 and week 30 of IFX treatment were 90. 0% (9/ 10),90. 0% (9/ 10)and 71. 4% (5/ 7),respectively,and the remission rates were 20. 0% (2/10),30. 0% (3/ 10)and 28. 6% (2/ 7),respectively. One patient was primary non-responder to IFX,and two lost response on week 30 (secondary non-response). Seven patients were followed up for 38 weeks. Two patients underwent colectomy. After (9. 6 ± 7. 0)months on average,endoscopic improvement occurred in 50. 0% (5/ 10)of patients,of which one achieved mucosal healing. During treatment course,one case of herpes zoster virus infection and one case of cytomegalovirus infection were recorded. Conclusions:This retrospective study revealed good short-term response to IFX treatment in patients with ASUC in China. It may reduce colectomy rate and promote mucosal healing. However,the rate of secondary loss of response is relatively high. During treatment course,viral infection should be monitored.

Efficacy of Infliximab as Rescue Therapy in Acute Severe Ulcerative Colitis / 胃肠病学

Background:Of patients with acute severe ulcerative colitis (ASUC),30% -40% is steroid-refractory and required second-line medical therapy or colectomy. Infliximab (IFX)may be effective as rescue therapy. Aims:To explore preliminarily the efficacy and safety of IFX as rescue therapy in ASUC in China. Methods:A retrospective study was conducted in 10 consecutive ASUC patients receiving IFX as rescue therapy from June 2012 to September 2016 at Peking Union Medical College Hospital. The modified Mayo score and laboratory parameters were compared at baseline and on week 2,week 12 and week 30 of the treatment course. Results:The response rates on week 2,week 12 and week 30 of IFX treatment were 90. 0% (9/ 10),90. 0% (9/ 10)and 71. 4% (5/ 7),respectively,and the remission rates were 20. 0% (2/10),30. 0% (3/ 10)and 28. 6% (2/ 7),respectively. One patient was primary non-responder to IFX,and two lost response on week 30 (secondary non-response). Seven patients were followed up for 38 weeks. Two patients underwent colectomy. After (9. 6 ± 7. 0)months on average,endoscopic improvement occurred in 50. 0% (5/ 10)of patients,of which one achieved mucosal healing. During treatment course,one case of herpes zoster virus infection and one case of cytomegalovirus infection were recorded. Conclusions:This retrospective study revealed good short-term response to IFX treatment in patients with ASUC in China. It may reduce colectomy rate and promote mucosal healing. However,the rate of secondary loss of response is relatively high. During treatment course,viral infection should be monitored.

Application value of methacetin enteric-coated tablets in patients with steroid resistant severe ulcerative colitis / 中国生化药物杂志

Objective To study the application value of methadazine enteric-coated tablets in the treatment of steroid resistant severe ulcerative colitis.Methods 110 cases of patients with steroid resistance severe ulcerative colitis in our hospital from June 2015 to December 2016 were randomly divided into experimental group and control group (n=55).The control group was given bacillus subtilis duplex living bacterium enteric capsules,the experimental group was given methadazine enteric-coated tablets.The total effective rate, Mayo score, cytokine levels change, C-reactive protein and erythrocyte sedimentation rate were Compared between two groups.Results The total effective rate of the experimental group was 96.36% higher than that of the control group 85.45%(P< 0.05).The Mayo score of the experimental group was (3.17±2.03)and the control group was (3.69±1.97), the difference was not statistically significant.The levels of IL-8、TNF-α in the experimental group were(17.33±2.18) pg/mL ,(18.33±2.23) ng/mL,which were significantly lower than the those of the control group (25.33±2.18) pg/mL, (25.93±1.54) ng/mL (P<0.05).The C-reactive protein in the experimental group was (10.33±2.11) mg/L the ESR (22.39±5.33) mm/h,which was significantly lower than that of the control group (27.27±3.97) mg/L, (33.17±4.93)mm/h (P<0.05).Conclusion Mesalazine is effective in the treatment of steroid resistant severe ulcerative colitis,which can effectively control the inflammation,,reduce the level of IL-8 and TNF-α, worthy of clinical promotion.

Controversias en el manejo de la de colitis ulcerosa grave en Chile / Controversies in the management of severe ulcerative colitis in Chile

Ulcerative colitis is a chronic inflammation in the mucosa layer of the colon characterized by activity and remitting episodes of varying severity and extension. Most of the flares are mild to moderate. They require outpatient treatment and have a good prognosis. The severe crises can have a high mortality if not treated on time. The success of the therapy depends on a multidisciplinary team.

La colitis ulcerosa en una inflamación crónica de la mucosa del intestino grueso que se caracteriza por episodios de actividad y remisiones de gravedad y extensión variable. La mayoría de las crisis son leves a moderadas, requieren tratamiento ambulatorio y son de buen pronóstico. Las crisis graves pueden llegar a tener una alta mortalidad si no son tratadas a tiempo. El éxito de la terapia depende de un equipo multidisciplinario.

Manejo de la colitis ulcerosa grave: experiencia a partir de un hospital ministerial / Management of severe ulcerative colitis: experience from a national health service hospital

Introduction: Ulcerative colitis (UC) may present, or evolve as severe crisis. Although guidelines have defined its management and timing in decision-making, this has not been implemented at national level. Objective: To describe the clinical characteristics and management of patients with severe UC in our hospital. Patients and Methods: Retrospective review of medical records of 116 patients with inflammatory bowel disease during the period 1975-2012. Of 97 patients with UC, 21 patients with at least one severe crisis were identified. Results: The median age among patients with UC crisis was 34 years (17-43). Ten patients debuted with severe crisis. Eleven were in maintenance treatment, all with 5-aminosalicylates (5- ASA), eight with systemic steroids and five with immunomodulators. During the crisis, colonoscopy was performed to 13 patients, 11 with extensive involvement and two left colitis. All patients received steroids and 5-ASA, 14 antibiotics, and seven immunomodulators. No patient received medical rescue therapy (cyclosporine/biological therapy). Nine patients required surgery, two due to toxic megacolon and seven due to intravenous-steroid refractory episode. Five patients received parenteral nutrition and six were hospitalized in the critical patients unit. The range of stay in the hospital was 9-51 days. Conclusions: In this study, a significant percentage of patients with CU presented a severe crisis without having a standardized management. It is necessary to establish a consensus for the multidisciplinary management of severe UC. No patient had access to cyclosporine/biological therapy, more than 40 percent of the cases required surgery. These therapeutic strategies should be incorporated into the therapeutic arsenal in hospitals.

La colitis ulcerosa (CU) puede debutar, o evolucionar, como crisis grave. Aunque guías han definido su manejo y temporalidad en la toma de decisiones,esto no ha sido masificado a nivel nacional. Objetivo: Describir las características clínicas y manejo de pacientes con CU grave en nuestro centro. Pacientes y Métodos: Revisión retrospectiva de fichas clínicas de 116 pacientes con enfermedad inflamatoria intestinal, durante el período 1975-2012. De 97 pacientes con CU se identifican 21 pacientes con al menos una crisis grave. Resultados: La mediana de edad en la crisis fue 34 años (17-43). Diez pacientes debutaron con crisis grave. Once estaban en tratamiento de mantención, todos con 5-aminosalicilatos (5-ASA), ocho con esteroides sistémicos y cinco con inmunomoduladores. Durante la crisis, se realizó colonoscopia a 13 pacientes, 11 con compromiso extenso y dos con colitis izquierda. Todos recibieron esteroides y 5-ASA, 14 antibióticos y siete inmunomoduladores. Ningún paciente recibió terapia médica de rescate (ciclosporina/terapia biológica). Nueve pacientes requirieron cirugía, dos por megacolon tóxico y siete por cortico-refractariedad. Cinco pacientes recibieron nutrición parenteral y seis fueron hospitalizados en una Unidad de Pacientes Críticos. El rango de estadía hospitalaria fue de 9-51 días. Conclusiones: En este estudio un porcentaje importante de los pacientes con CU presentó una crisis grave, sin tener un manejo estandarizado. Es necesario establecer un consenso para el manejo multidisciplinario de la CU grave. Ningún paciente tuvo acceso a ciclosporina/ terapia biológica, requiriendo cirugía más de 40 por ciento de los casos. Estas estrategias terapéuticas deben ser incorporadas al arsenal terapéutico hospitalario.

Manejo quirúrgico en la colitis ulcerosa grave: alternativas técnicas / Severe ulcerative colitis: surgical options

Surgical options for treatment of severe ulcerative colitis are presented. The preferred treatment should consider clinical presentation (elective or emergency), age, co-morbidities, functional status, previous continence and acceptance of a temporary or permanent ostomy. In emergency condition the alternative is subtotal colectomy with end ileostomy and closure of the rectal stump. This removes the extended disease, can optimize medical therapy and leads the patient to an optimal condition for elective surgery. In the case of elective condition the patient’s functional status and continence becomes more important. The most commonly used option is the proctocolectomy with ileal reservoir and anal anastomosis and loop ileostomy. Functional results are appropriate and even though morbidity is high, there is an adequate control of the disease with an overall 8 percent failure of the reservoir. Other alternatives include proctocolectomy with permanent ileostomy, the continent ileostomy and total colectomy with ileo rectal anastomosis.

Se presentan las alternativas quirúrgicas para el tratamiento de la colitis ulcerosa grave. La elección del tratamiento debe considerar la forma de presentación clínica (electiva o urgencia), la edad del paciente, su comorbilidad y estatus funcional, la continencia previa a la cirugía y la aceptación del paciente de una ostomía transitoria o definitiva. En condición de urgencia o emergencia la alternativa recomendada es la colectomía total o subtotal con ileostomía terminal y cierre del muñón rectal. Con esto se logra la remoción de la mayor parte de la enfermedad, permite optimizar la terapia médica y llevar al paciente a una condición óptima para la cirugía electiva. En condición electiva cobra mayor importancia el estado funcional del paciente y su continencia. La opción más utilizada es la proctocolectomía con reservorio ileal, anastomosis reservorio anal e ileostomía en asa transitoria de protección. Los resultados funcionales son adecuados y aunque la morbilidad es alta, existe un adecuado control de la enfermedad, con una falla global del reservorio de 8%. Otras alternativas incluyen la proctocolectomía con ileostomía definitiva, la ileostomía continente y la colectomía total con anastomosis íleo rectal.

Colitis ulcerativa aguda severa: Presentación de un caso y revisión de la literatura / Acute severe ulcerative colitis: case report and literature review

La colitis ulcerativa aguda severa es una urgencia médica que puede comprometer la vida del paciente; requiere una alta sospecha diagnóstica para establecer un manejo adecuado y oportuno, y prevenir complicaciones. Es necesario determinar factores pronósticos para identificar pacientes de alto riesgo. Los esteroides intravenosos son tratamiento de primera línea, en caso de no respuesta, el uso de terapia de "rescate" con infliximab o ciclosporina reduce el riesgo de colectomía a corto plazo, sin comprometer la seguridad del paciente.

Acute severe ulcerative colitis is a potentially life-threatening condition that requires a pro-active approach with either effective medical treatment or timely colectomy. It is very important to identify at an early stage those who are likely to fail intensive treatment. Although intravenous steroids remain the first line, for those who fail, currently available 'rescue' medical therapy with infliximab and cyclosporine may reduce the risk of colectomy in the short term without compromising safety.