Medical Management of Chronic Ulcerative Colitis
In the twenty-first century, the management of inflammatory bowel disease can be considered a subspecialty within Gastroenterology and Colon & Rectal Surgery, “IBD-ology.” This is mainly due to the development of complex, expensive medical treatments
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Key Concepts • CUC is highly prevalent in North America and Europe, and its incidence is increasing globally. • CUC has an unknown etiology, but the pathogenesis is believed to be multifactorial, with an impaired mucosal immune regulation and unknown environmental conditions or trigger(s). • The incidence of colorectal cancer in CUC is increasing, and the presence of low-grade dysplasia is an indication for colectomy given an unacceptably high rate of synchronous or metachronous cancers. • Surgeons must be familiar with the numerous medical treatments for CUC, including their side effects. • Mild-to-moderate CUC is typically treated in a bottom-up manner with oral aminosalicylates, and if steroids are required for flares, then the patient is transitioned to AZA/6MP or a biologic agent to wean the steroids. • Moderate-to-severe disease is typically treated in a topdown manner with combination therapy with a biologic agent and immunomodulator, often under the cover of temporary steroid treatment. • Medical patient who may require surgery should be aggressively optimized in terms of anemia, malnutrition, and VTE prophylaxis. • Pouchitis is common and responds promptly to oral antibiotic use. Patients with “Crohn’s-like” picture of the pouch (indeterminate pouchitis) may benefit from additional medical therapy.
Electronic supplementary material: The online version of this chapter (doi:10.1007/978-3-319-25970-3_46) contains supplementary material, which is available to authorized users.
Part 1: Defining CUC Introduction Chronic ulcerative colitis (CUC) is an idiopathic, recrudescent chronic disease of colonic mucosal ulceration (Figure 46-1) with a prevalence of well over 600,000 affected persons in North America [1]. CUC is one end of the spectrum of idiopathic inflammatory bowel disease (IBD) (Figure 46-2). Although the etiology of CUC remains idiopathic, it is generally accepted that the pathogenesis of CUC is multifactorial, with an impaired mucosal immune regulation and unknown environmental conditions or trigger(s) playing complementary roles. The vast majority of patients with CUC will require multiple medications to control disease over the course of their lifetime. Surgeons managing patients with IBD must be intimately familiar with medical management as the risks and benefits of surgery must be weighed against those of continued medical treatment in both elective and acute settings. In this chapter, in Part 1 we will discuss the definition and severity classifications of CUC, and we will review the epidemiology. Part 2 will review the armamentarium of medications currently available. In Part 3 we will present an algorithmic approach to CUC treatment based on severity and extent, as well as that of pouchitis. This chapter, intended for a surgical audience, aims to be a pragmatic clinical overview with clinical pearls rather than being an exhaustive review. Wilks & Moxon at Guy’s Hospital, London, originally described CUC in 1875. Symptoms include chronic diarrhea, often bloody, accompanied by tenesmus and def
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