3156 A Case of Rapidly Progressing Ulcerative Colitis

Abstract

INTRODUCTION: Ulcerative colitis is often characterized by a relapsing and remitting course. Acute flare ups may present as a serious illness. Most patients show a good response to intravenous corticosteroids which is the cornerstone of management of flare ups. However, a number of patients may develop a rapidly progressive illness and will need a colectomy. We present one such case where a colectomy was needed within four weeks of presentation. CASE DESCRIPTION/METHODS: Case report: A 30-year-old female presented to the emergency department for evaluation of high grade fever and abdominal pain associated with vomiting and foul-smelling, non-bloody, diarrhea 5-6 times a day. She had a history of developmental delay with refractory epilepsy but no previous reports of bowel symptoms. Abdominal X-ray showed small bowel obstruction. Further, a dilated colon with intramural edema was seen on CT scan along with an obstruction of distal small bowel. Stool was positive for leukocytes and calprotectin. CRP was elevated. Blood and stool cultures were negative. Three days later, she started having bloody diarrhea. Flexible sigmoidoscopy showed features of chronic severe colitis with ulceration. The tissue was negative for cytomegalovirus. She was diagnosed with inflammatory bowel disease after positive serology and treated with mesalamine and intravenous steroids followed by infliximab infusions with minimal improvement. She developed recurrent bowel obstructions and toxic megacolon for which she underwent a total colectomy with end ileostomy which was life saving for her. DISCUSSION: Acute severe colitis is a medical emergency and despite improvements in medical care, a substantial number of patients fail to achieve remission. Based on the criteria developed by Truelove and Witt, acute severe ulcerative colitis is characterized by the presence of more than 6 bloody stools per day along with any one of the following: tachycardia >90 bpm, fever >37.8 °C, Hb <10.5 gm/dL, and/or ESR >30 mm/h. Nearly 20% of patients end up needing a colectomy during first admission. Intravenous corticosteroids are the mainstay of initial therapy. Response to steroids should be assessed after 3 days. This is indicated by an improvement in symptoms as well as laboratory parameters like CRP, hemoglobin and serum albumin. Partial or non-responders should be considered for alternative therapies. Colectomy is regarded as a lifesaving procedure in those not responding to medical treatment and must be considered as the next therapeutic step.