Medication Summary
Start the patient on antibiotics to cover the colonic bacterial flora. Any number of antibiotics that primarily cover gram-negative and anaerobic bacteria can be administered. In addition, begin the administration of steroids. Either hydrocortisone 100 mg IV piggyback (IVPB) every 6 hours or methylprednisolone 60 mg IVPB every 24 hours is acceptable. The latter has greater relative anti-inflammatory potency and less relative mineralocorticoid potency.
As previously mentioned, some reports indicate that cyclosporine A may be effective against toxic megacolon (toxic colitis), or TM (TC), and severe ulcerative colitis. However, cyclosporine has significant adverse effects, including immunosuppression and opportunistic infections, hypertension, renal toxicity, and neurologic complications.
Corticosteroids
Class Summary
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids also modify the body's immune response to diverse stimuli.
Hydrocortisone (Solu-Cortef, Cortef)
Hydrocortisone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Methylprednisolone (A-Methapred, Depo-Medrol, Medrol, Solu-Medrol)
Methylprednisolone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Immunosuppressant Agents
Class Summary
Immunosuppressant agents inhibit immune reactions resulting from diverse stimuli.
Cyclosporine (Neoral, Gengraf, Sandimmune)
Cyclosporine is used in acute, severe ulcerative colitis that is refractory to IV corticosteroids. An 11-amino acid cyclic peptide and a natural product of fungi, it acts on T-cell replication and activity.
Cyclosporine is a specific modulator of T-cell function and an agent that depresses cell-mediated immune responses by inhibiting helper T-cell function. Preferential and reversible inhibition of T lymphocytes in the G0 or G1 phase of the cell cycle is suggested.
Cyclosporine binds to cyclophilin, an intracellular protein, which, in turn, prevents formation of interleukin-2 and the subsequent recruitment of activated T cells.
Cyclosporine has about 30% bioavailability, but there is marked interindividual variability. This agent specifically inhibits T-lymphocyte function, with minimal activity against B cells. Maximum suppression of T-lymphocyte proliferation requires that the drug be present during the first 24 hours of antigenic exposure.
Cyclosporine suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions (eg, delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, graft-vs-host disease) for a variety of organs.
Immunomodulators
Class Summary
Immunomodulatory agents regulate immune reactions that are responsible for inflammation.
Infliximab (Remicade)
Infliximab neutralizes the cytokine TNF-alpha and inhibits its binding to the TNF-alpha receptor. Mix in 250 mL normal saline for infusion over 2 hours. It must be used with a low-protein-binding filter (1.2 µm or less).
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A 22-year-old man presented with abdominal pain, passage of blood and mucus per rectum, abdominal distention, fever, and disorientation. Findings from sigmoidoscopy confirmed ulcerative colitis. Abdominal radiographs obtained 2 days apart show mucosal edema and worsening of the distention in the transverse colon. The patient's clinical condition deteriorated over the next 36 hours despite steroid and antibiotic therapy, and the patient had to undergo a total colectomy and ileostomy.
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A 72-year-old woman presented with vomiting and abdominal distention. The supine (right) and erect (left) plain abdominal radiographs show gross dilatation of the colon with multiple air-fluid levels. On further questioning, the patient revealed that she was taking diuretics for hypertension. Blood biochemical tests revealed markedly lowered potassium levels. After potassium replacement therapy, the patient's pseudo-obstruction completely resolved.
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Gross pathology specimen from a case of pseudomembranous colitis demonstrating characteristic yellowish plaques.
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Computed tomography scan from a patient with pseudomembranous colitis demonstrating the classic accordion sign.
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Plain abdominal radiograph from a patient with known ulcerative colitis who presented with an acute exacerbation of his symptoms. This image shows thumbprinting in the region of the splenic flexure of the colon.
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Increased postrectal space is a known feature of ulcerative colitis.
