Internal Medicine

0521779407-21 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 18:59

1480 Ulcerative Colitis

■maximum 7–10 days observation on this regimen; watch for mega-

colon or other signs of impending perforation; have a colorectal sur-

geon follow

■failure to improve mandates colectomy, or cyclosporine in highly

selected individuals who decline surgery and agree to long-term

maintenance therapy with Aza or 6MP (or methotrexate if unable

to tolerate Aza or 6MP)

■start cyclosporine (CSA; only at a transplant center where daily accu-

rate levels of CSA are available) at 4 mg/kg/day and follow whole-

blood levels daily to maintain the level at 200–400

■if remission is achieved with iv CSA, start oral CSA, an oral aminos-

alicylate, Aza or 6MP (may take 3–6 months to work) and Bactrim

(three times/week) for Pneumocystis prophylaxis

■taper off steroids and CSA over the next 3 months

■side effects of CSA include nephrotoxicity, seizures, hypertension,

opportunistic infections, hirsutism, tremor and gingival hyperplasia

Colectomy

■Indications:

➣urgent or emergent:

failure to achieve remission with maximum medical manage-

ment

perforation, or impending perforation

➣elective:

confirmed dysplasia and/or carcinoma

failure to maintain remission with immunomodulatory ther-

apy and without long-term or frequent systemic steroids

pyoderma gangrenosum resistant to corticosteroids or

cyclosporine

➣Procedures:

proctocolectomy with a one- or two-stage ileal pouch-anal

anastomosis (IPAA)

for emergent surgery, subtotal colectomy with Brooke ileo-

stomy and Hartmann procedure; later an elective IPAA

➣Complications:

multiple BMs (6–8/day), nocturnal incontinence (small

amount), pouchitis (>50%; treat with metronidazole and

cort enemas), pouch failure (5%), pouch dysplasia (requires

surveillance)

follow-up

■Frequent visits to assess symptoms and laboratory tests, particularly

CBC, LFTs