Fulminant Colitis

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Fulminant Colitis
M62 Coloproctology course 2004

• New Challenges

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Issues

• Changing patterns of disease
• Developments in drug therapy
• Timing surgical intervention
• Surgical practice

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Patterns of Disease IBD

• Rising incidence of Crohns disease
• Copenhagen
• presentation
• investigation

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Patterns of Disease IBD

• Rising incidence of Crohns disease
• Copenhagen
• presentation
• investigation

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Patterns of Disease
UC
Crohns
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Patterns of Disease non-IBD

• Clostridum difficile
• Vascular disease
• Immune-compromised

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Pseudomembranous colitis
Source Nr Cases Cdiff Severe Mort
Hosp 2300 64 60
Hosp 157 51 20
NOF 239 17 35
Gastro 13 38

Dallal 2002 Morris 2002 Sharma 2003 Koss 2004

• Rising incidence 30-100/10yrs
• Recurrent attacks 20
• Subtotal colectomy 100 mortality
• Pre-op D 46 Koss 2004

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Pseudomembranous colitis

• Immunosupression
• Lung TT
• CT diagnosis

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Cardiac Patients
Centre Nrs GI Compl C- diff Isc-aemia Mort
Texas 11,000 147 18 17 22
Frankf. 1,000 23 85

• Major GI complications- high mortality
• Surgical decisions - complex
• Cardiac surgery scope stool cultures

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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 agen ve Rahbar 2003
• Mimics PMC Olfinlade 2001
• Study of CMV/PMC in acute colitis required

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Medical Managementdevelopments

• The Oxford criteria
• the five day rule Truelove _at_ Jewell 1974
• Azathioprine
• maintenance of remission
• Cyclosporin
• induction of remission McCormack G 2002
• VanAssche G 2003

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Medical Managementchallenges

• Uncertain end points
• Masked sepsis
• Late relapse
• immunosuppression Mallant-Hent 2003

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Surgical Issue

• UC - fragile colon
• Crohns - loss of planes
• Rectal stump(ed)

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Surgical Issue

• UC - fragile colon
• Crohns - loss of planes
• Rectal stump(ed)

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Surgical Developments

• One stage reconstruction
• cyclosporin Hyde GM 2001
• Laparoscopy Hurley BW 2002
• Marcello PW 2001
• - interval procedure
• Reconstruction in Crohns disease?

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New Challenges?

• Team management Truelove _at_ Jewell 1974
• MDM
• Shared care
• Mixed wards

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Patterns of Disease non-IBD

• Broad spectrum antibiotics
• pseudomembranous colitis
• Multisystem disease
• ischaemic colitis
• Immune-compromised
• viral infections
• multifactorial disease

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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

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