Intended for healthcare professionals

Rapid response to:

Practice

Ulcerative colitis: diagnosis and management

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7563.340 (Published 10 August 2006) Cite this as: BMJ 2006;333:340

Rapid Response:

Avoid delaying surgery in patients with severe ulcerative colitis.

Collins & Rhodes [1] provide a comprehensive review of the
medical treatments for ulcerative colitis but surgical management options
are only very briefly covered, despite their acknowledgement in the final
paragraph that the overall colectomy rate is still about 25%. Their
comment that colectomy may be needed if medical treatment does not produce
a substantial response within seven to ten days cannot go unchallenged.

Approximately 15% of patients with ulcerative colitis will have a
severe attack requiring hospitalization at some time during their illness.
These patients are traditionally treated with intravenous corticosteroids,
with a response rate of approximately 60%, the remaining 40% requiring
colectomy, which essentially cures the patient. It is dangerous to persist
with medical treatment if the response is inadequate. If surgery is
delayed, the general condition may deteriorate and the patient is at risk
of multiple organ dysfunction syndrome (MODS) [2], which may adversely
affect the outcome. The early identification of patients likely to fail
medical therapy aids the decision either to operate, and thus lower
operative morbidity and mortality, or to offer second line medical therapy
such as ciclosporin.

Many scoring systems for ulcerative colitis exist and are useful in
stratifying the disease with the aim of predicting the failure of medical
therapy and identifying likely surgical candidates early. One of the most
widely used is that of Travis et al [3] who demonstrated that it could be
predicted on day 3, that 85% of patients with more than eight stools on
that day, or a stool frequency between three and eight together with a CRP
> 45 mg/l, would require colectomy. Numerous other studies have also
shown that patients likely to require colectomy could be identified on day
3 of medical treatment [4-6].

Although it has often not been possible to demonstrate a clear
statistically significant relationship between postoperative mortality and
the time between admission and operation [7] it seems nonsensical to
persist with medical treatment for up to 10 days that is highly unlikely
to work after the 3rd day when surgery may offer cure and to delay it may
be to the detriment of the patient. In cases of severe ulcerative colitis
most surgeons would advocate joint care by a physician and a surgeon in
order to avoid any unnecessary delay in surgery.

1. Collins P, Rhodes J. Ulcerative colitis: diagnosis and management.
BMJ 2006;333;340-343.

2. Caprilli R, Latella G, Vernia P, Frieri G. Multiple organ dysfunction
in ulcerative colitis. Am J Gastroenterol 2000;95(5):1258-62.

3. Travis SP, Farrant JM, Ricketts C, Nolan DJ, Mortensen NM, Kettlewell
MG, Jewell DP. Predicting outcome in severe ulcerative colitis. Gut 1996
Jun;38(6):905-10.

4. Ho GT, Mowat C, Goddard CJ, Fennell JM, Shah NB, Prescott RJ, Satsangi
J. Predicting the outcome of severe ulcerative colitis: development of a
novel risk score to aid early selection of patients for second-line
medical therapy or surgery. Aliment Pharmacol Ther 2004;19:1079-1087.

5. Lindgren SC, Flood LM, Kilander AF, Lofberg R, Persson TB, Sjodahl RI.
Early predictors of glucocorticosteroid treatment failure in severe and
moderately severe attacks of ulcerative colitis. Eur J Gastroenterol
Hepatol 1998 Oct;10(10):831-5.

6. Elloumi H, Ben Abdelaziz A, Derbel F, Jmaa A, Lassoued Y, Arfaoui D,
Ben Ali A, Letaief R, Hamida RB, Ghannem H, Ajmi S. Predictive factors of
glucocorticosteroid treatment failure in severe acute idiopathic colitis.
Acta Gastroenterol Belg 2005 Apr-Jun;68(2):226-9.

7. Ritchie JK, Ritchie SM, McIntyre PB, Marks CG. Management of severe
acute colitis in district hospitals. J Roy Soc Med 1984;77:465-471.

Competing interests:
None declared

Competing interests: No competing interests

20 August 2006
Neil J Smart
SpR General Surgery
North Bristol NHS Trust