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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Diagnosis
History
Diagnosis is achieved through a combination of history alongside biochemical, endoscopic,stool,andhistologicalfindings.Commonhistoryfindingsinclude:
Rectalbleeding Diarrhoea Increaseinbowelfrequency Urgency,tenesmus,andincontinence Abdominalpain(typicallycrampsrelatedtotheneedtodefecate) Constitutionalsymptoms,e.g.fatigue In severe disease, systemic symptoms may manifest, e.g. fever and anorexia. Weight loss is relativelyuncommonandtypicallyoccursinlatepresentationsofextensivedisease.
Alsoaskabout:
RecenttravelhistoryregardingGIinfections Smokinghistory:typicallyex-ornever-smokers FamilyhistoryofIBD.
Examination
Mayhavenospecificsignsinpatientswithmildtomoderatedisease Abdominaltenderness(especiallyduringacuteflare) Extraintestinalmanifestations(Box32.1) Signsofanaemia,e.g.conjunctivalpallor,koilonychia Rectalexaminationisusuallyunnecessarysincethepatientwillneedendoscopicinvestigation
AcutesevereflareofUC:tachycardia(>90bpm)and/orpyrexia(>37.8°C).
Box32.1Extraintestinalmanifestationsofulcerativecolitis
Erythemanodosum Pyodermagangrenosum Uveitis Fingerclubbing Arthropathy:largejointarthritisandsacroiliitis Primarysclerosingcholangitis(PSC).
Investigations
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Bedside
Pulserateandtemperature Stoolchart—monitorbowelfrequency,stoolconsistency,andpresenceofbloodwithstool.
Bloods
FBC:lowhaemoglobin,raisedleucocytesandplatelets CRPorESR(thelatterisrarelyperformed) Electrolytes:forbaselinelevel LFT: alanine aminotransferase (ALT) and alkaline phosphatase (ALP) may be ↑ if concomitant PSC.Albuminmaybelowinmoreseveredisease Ironstudies.
Imaging
Abdominal X-ray—to check for toxic megacolon in acute severe flare of UC (internal colon diameter≥5.5cm) CTifsuspectedperforation(moreseverepersistentabdominalpain,and/orsepsis).
Other
Stoolsample:
Faecalcalprotectin(FC)—markerofcoloninflammation(↑).Usefulformonitoringofdisease activity. Not useful as a diagnostic tool, but typically used in primary care for its good negativepredictivevalue(i.e.toexcludeinflammatoryboweldisease) Microbiology analysis to rule out infective causes of bloody diarrhoea, especially
Clostridiumdifficile
Testforova,cysts,andparasitesdependingonthepatient’sdemographicsandtravelhistory
LowerGIendoscopy—ileo-colonoscopyorflexiblesigmoidoscopy:
Continuousinflammationvisualizedintherectumandextendingproximally(unlikeCDwhich has‘skip’lesions) Mucosa—loss of vascular pattern, bleeding and friability, erosions, and/or ulcers. Larger (>5mm)and/ordeepulcersaretypicallyrepresentativeofmoreseveredisease Biopsy—colonicandrectalbiopsiesshouldbetaken.HistologicalfeaturesofUCarelistedin
Box32.2
Flexible sigmoidoscopyispreferredinsevereactivedisease asbowel preparationmaynot betolerated,andthereisahigherriskofperforationwithcolonoscopy.
Box32.2Histologicalfeaturesofulcerativecolitis
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Basalplasmacytosis(earliestfeature) Cryptdistortion Cryptabscesses Mucosalatrophy Absenceofgranuloma(granulomasseeninCD) Continuous colonic involvement with clear demarcation of inflammation plus rectal involvement.
Source:datafromMaaserC,etal(August2018)ECCO-ESGARGuidelineforDiagnosticAssessment inIBDPart1:Initialdiagnosis,monitoringofknownIBD,detectionofcomplications.Journalof Crohn’sandColitis13(2):144–164K.
Management
Guided by disease severity and distribution of UC. Truelove and Witts’ criteria are predominantlyusedtoassessdiseaseseverityinacuteflares(Table32.1).
Table32.1AssessingseverityinUCflares(TrueloveandWitts’criteriamodifiedto includeCRP)
Variable MildUC ModerateUC SevereUC
Motions/day <4 4–6 >6
Rectalbleeding Small Moderate Large
Temperature Apyrexial 37.1–37.8°C >37.8°C
Restingpulse(bpm) <70 70–90 >90
Haemoglobin(g/L) >110 105–110 <105
ESR/CRP <30 >30
Source:datafromTrueloveSC,etal(October1955)CortisoneinUlcerativeColitis.BritishMedical Journal2(4947):1041–8.
Patienteducation
Patient to monitor symptoms and contact IBD team/nurse if they develop persistent changes in symptoms.
Pharmacologicalmanagement
Acuteflare
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Mild–moderateUC:
For proctitis alone, topical 5-aminosalicyclic acid (5-ASA) is first line (can be combined withtopicalsteroidsororal5-ASAforgreatereffectiveness) Oral5-ASAincombinationwithtopical5-ASAforleft-sidedandextensivedisease
OralsteroidssuchasbudesonideMMX®(Cortiment®)orprednisoloneshouldbeconsidered
incasesrefractoryto5-ASA Severe UC: indicationfor admissionto hospital in those patientsfulfilling Truelove and Witts’ criteria.Thismeans>6bloodystools/dayplusoneormoreofthecriteria(temperature>37.8°C, pulserate>90bpm,haemoglobin<105g/L,CRP>30mg/L):
TreatwithIVsteroids,thromboprophylaxis,andIVrehydrationwithelectrolyte replacement
(willtypicallyrequirepotassium>60mmol/day)
Maintainhaemoglobinof>8g/dLwithtransfusion
Considermedicalrescuetherapywithinfliximaborciclosporinifnoorincompleteresponse
tosteroidbyday3.Day3criteriaare>8stools/day,or3–8stools/dayandCRP>45mg/L
Ifnoresponsetorescuetherapyafter4–7days,colectomyisrecommended.
Thromboprophylaxis
Inpatients with UC should be prescribed thromboprophylaxis given their ↑ risk of thromboembolism,despitebloodydiarrhoea.
Chronicmanagement
Patients should remain on long-term maintenance treatment with the aim of achieving steroidfreeremission.
Steroid-sparingtherapy:
Patients requiring steroids despite 5-ASA treatment, and with steroid-responsive disease,
shouldbecommencedonthiopurinesinthefirstinstance.Evidencesuggeststhereislittlerole
for methotrexate as monotherapy in UC, but it does still have use as a concomitant
immunomodulatorwithanti-TNFtherapy
Forthosewithactivediseasedespite5-ASAandthiopurines,orthosewithsteroid-refractory
disease, there are now a number of medical options. These include anti-TNF agents (e.g.
infliximab, adalimumab), anti-integrin therapy (vedolizumab), JAK inhibitors (tofacitinib),
andanti-IL-12p40(ustekinumab)
Specialconsiderationsforprescribingsteroid-sparingtreatmentsarelistedinTable32.2.
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Table32.2Prescribingthiopurines,anti-TNFagents,vedolizumab,andtofacitinib
Thiopurines Anti-TNF Vedoli-
zumab
Tofacitinib
Before starting
Checkthiopurine methyltransferase (TMPT)levels CheckbaselineFBC, U&E,LFT Checkserologyfor: HepatitisB/C,HIV. Vaccinate/treatif appropriate
Checkserologyfor: HepatitisB/C,HIV,varicella­zostervirus(VZV) AlsoperformTBtestingasper localguidelines.Vaccinate/treat ifappropriate
No specific checks
Checkserologyfor: HepatitisB/C,Epstein–Barr virus,HIV,VZV Vaccinate/treatifappropriate Checkfastinglipids Shinglesvaccineifpossible ConsiderriskofDVTand pulmonaryembolism(PE). Usealternativeagentif possibleifadditionalVTE risks
Monitoring FBCandLFTevery
otherweekfor1month,
Checkanti-TNFtroughlevels ifincompleteorlossof response,andatleastevery6– 12monthsinstablepatients
No specific monitoring
Checkfastinglipidsat8 weeks CheckFBCandLFTat4 and8weeks,andthenevery 3months
Cautions Patientshouldhavealow
thresholdforseeking medicalattentionifthey developfever/infection
Patientshouldhavealow thresholdforseekingmedical attentioniftheydevelop fever/infection
No specific cautions
Patientshouldhavealow thresholdforseeking medicalattentionifthey developfever,shingles,or symptomsofDVT/PE
Source:datafromtheBNF.
Surgicalmanagement
Subtotal colectomy withileostomymay be required after failure ofmedical treatmentor due to complications(e.g.colonicperforation) Subsequentcompletionproctectomyandpermanentileostomy,orformationofileo-analpouch,isa decisiontobetakenafterfullrecoveryfromsubtotalcolectomy.
Psychosocialconsiderations
Livingwithsymptomsof↑bowelfrequencyandurgency:
Feelingsofsocialembarrassment
Adolescentsat↑riskofsocialisolationanddepression Psychologicalimpactofstomaformation Directpatientstostomaspecialistnursesandsupportgroupstohelpwiththeabovepoints.
Complications
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Strictures Fibrosis Toxiccolonicdilatation Bowelperforation ↑riskofcolorectalcancer Thromboembolism.
Monitoringandfollow-up
Mostpatientswillrequirelong-termmaintenancetreatment,usuallywith5-ASA/mesalazine FollowupwithIBDteamatintervalsappropriatefordiseaseactivity.Thiswillincludeareview ofsymptoms,seruminflammatorymarkers,±faecalcalprotectin±endoscopicassessment Patientsonthiopurinesoranti-TNFagentsshouldhavetheirdruglevelsmonitored.
Endoscopy
If patientsare asymptomaticatfollow-upbuthaveabnormalinflammatorymarkersand/orfaecal calprotectin,considerendoscopytoassessforactivedisease Monitor mucosal healing with endoscopy or faecal calprotectin 3–6 months after commencing treatmentinpatientswhoimproveclinicallywithpharmacologicaltreatment Ifnewsymptoms,poorresponsetotreatment,orsevererelapse,repeatendoscopy Surveillancecolonoscopyshouldbecarriedout(between5-yearlyandannually,dependingonrisk stratification)dueto↑riskofcolorectalcancerassociatedwithUC.Surveillanceshouldbemore frequentinpatientswithconcurrentPSC.
Specialconsiderations
Pregnancy
Fertilityisunaffectedbywell-controlledUC Patientsconceivingduringinactivediseasehavesimilarriskofrelapsetonon-pregnantpatients For the majority of UC medications there is no evidence of harm during pregnancy and breastfeeding, although pregnancy must be avoided if the patient is taking methotrexate or tofacitinib Investigation during pregnancy should always be considered carefully and discussed with the patient. There is no evidence of harm with flexible sigmoidoscopy, although this is avoided if possible,particularlyinthefirsttrimestergiventhenaturalfrequencyofmiscarriageinthisstage ofpregnancy.MRIistypicallyonlyperformedinthesecondandthirdtrimesters.
Furtherreading
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1.Wilkinson IB,RaineT,WilesK, etal. (2017). Ulcerativecolitis. In: OxfordHandbook of Clinical Medicine, 10th ed (pp. 262–3). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199689903.003.0006
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Part5
Hepatobiliary
Acuteliverfailure
Alcohol-relatedliverdisease
Alcoholusedisorders
Livercirrhosis
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Chapter33
Acuteliverfailure
Guideline: EuropeanAssociationfortheStudyoftheLiver(EASLClinical
Practical Guidelines on the management of acute(fulminant) liver failure):
https://www.journal-of-hepatology.eu/article/S0168-8278(16)30708-5/fulltext
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Acute liver failure (ALF) refers to an acute episode of liver dysfunction in a patient without previously diagnosed liver disease, resulting in coagulopathy and hepatic encephalopathy (HE). ALF typically begins with an acute liver injury, suggested by derangedliverfunctionandcoagulopathy.
Diagnosis
ThediagnosisofALFisdependenton:
Acuteliverinjury—a2–3×increaseintransaminases(ALTandaspartateaminotransferase(AST)) —andimpairedliverfunctionevidencedbyjaundiceandcoagulopathy ThepresenceofHE.
Coagulopathy is defined as INR >1.5 and/or prolonged PT. Depending on the time of onset of HE from the time jaundice was noted, ALF can be further divided into hyperacute (7 days), acute (8–28days), andsubacute(5–12weeks).The timeframecan helptosuggestthepotentialcauseofALF(Table33.1).
https://t.me/med1917
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HEisnecessaryforadiagnosisofALF.Itsabsenceinthepresenceofnewlyderanged liverfunctionandcoagulopathysuggestsanacuteliverinjury,butnotALF.
History
A focused history will help make a prompt diagnosis of ALF and give clues to the aetiology, guiding management and allowing prognostication. Ask about onset of symptomsandsignssuggestiveofliverdysfunctionsuchas:
Jaundice Confusion Atraumatic/spontaneousbleeding Generalmalaise Nauseaorvomiting Abdominalswelling(ascitesismoretypicalofchronicliverdiseasebutcanoccurinBudd–Chiari syndrome) Rightupperquadrant(RUQ)pain.
Takeathoroughsocialhistory,includingforeigntravel,occupation,alcoholuse,anddrug use. Besureto ask aboutregularand acutemedications, includingover-the-counterand herbalmedications!HEcanbesubtlesoithelpstohaveacollateralhistory.Considerthe timeframeofsymptomsasthismayprovideacluetothediagnosis(Table33.1).
https://t.me/med1917
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