WBR1114

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Gastrointestinal
Prompt	[[Prompt::A 30 year old male comes to the emergency department with complaints of fever, generalized abdominal pain and bloody stools. He was diagnosed with ulcerative colitis 1 year back and has been on and off sulfasalazine treatment. His flare up started 2 days ago that quickly progressed to severe abdominal pain and multiple bloody stools. He does not have any other complaints. He does not smoke, but consumes alcohol occasionally. On examination his vitals are pulse: 94/min, BP: 140/80 mmHg and temperature: 38 degree Celsius. Abdominal examination reveals hypoactive bowel sounds and generalized distension with rebound tenderness. Abdominal X-ray shows colonic dilatation of > 6cm with some air fluid levels. There is no pnueumoperitoneum. Initial lab evaluation shows Hb: 10 g/dl, WBC: 18,500/mm3, platelets: 330,000/mm3, blood glucose: 100 mg/dl, serum creatinine: 1mg/dl and potassium: 3 mEq/L. Stool studies are negative for infectious etiology. Which of the following would the most appropriate next step in the management of this patient?]]
Answer A	AnswerA::Surgical consultation for colectomy
Answer A Explanation	[[AnswerAExp::Patients with toxic megacolon (transverse colon diameter ≥6 cm or cecum >9 cm with systemic toxicity) who do not respond to therapy within 72 hours and those with fulminant colitis without toxic megacolon who fail treatment with initial IV steroids and cyclosporine or infliximab therapy within four to seven days require colectomy.]]
Answer B	AnswerB::Intravenous glucocorticoids
Answer B Explanation	[[AnswerBExp::Patients with severe and fulminant colitis with intestinal dilation (transverse colon diameter ≥5.5 cm) should be immediately treated with intravenous glucocorticoids, prednisolone (30 mg IV every 12 hours) or methylprednisolone (16 to 20 mg IV every eight hours) without any delay with clinical evaluation done in 72 hours of start of treatment.]]
Answer C	AnswerC::Oral glucocorticoids
Answer C Explanation	[[AnswerCExp::Patients with severe ulcerative colitis without evidence of fulminant colitis features and toxic megacolon should be initially treated with combination therapy with high dose oral glucocorticoids and high dose oral 5-aminosalicylic acid. A switch to oral glucocorticoids is done in patients with fulminant colitis features and toxic megacolon after the intial IV steroid treatment response. This patient has toxic megacolon and hence should be started on aggressive intravenous steroid therapy.]]
Answer D	AnswerD::Intravenous infliximab
Answer D Explanation	[[AnswerDExp::IV infliximab can induce remission rapidly and can be used for the maintenance of remission in patients with severe colitis and fulminant colitis without toxic mega colon not responding to initial IV steroids. IV Infliximab can also be used induce remission in steroid refractory ulcerative colitis patients. This patient has toxic megacolon and hence should be started on aggressive intravenous steroid therapy.]]
Answer E	AnswerE::Broad spectrum antibiotics and opiods
Answer E Explanation	[[AnswerEExp::Anticholinergic, antidiarrheal agents, NSAID’s and opioid drugs should be discontinued in patients with severe and fulminant colitis due to the risk of precipitating toxic megacolon.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::Ulcerative colitis (Colitis ulcerosa, UC) is a form of inflammatory bowel disease (IBD), a form of colitis, specifically limited to the large intestine or colon, characterized by relapsing and remitting episodes of inflammation limited to the mucosal layer of the colon. The main symptom of active disease is usually diarrhea mixed with blood, of gradual onset. The management of ulcerative colitis varies according to the severity of disease presentation. Fulminant colitis refers to a subgroup of severe ulcerative colitis that have more than 10 stools per day, continuous bleeding, abdominal pain, distension, and acute toxic symptoms with a potential risk of progressing to toxic megacolon and bowel perforation. Patients with intestinal dilation (transverse colon diameter ≥5.5 cm) should receive decompression with a nasoenteric tube and immediately treated with intravenous glucocorticoids, prednisolone (30 mg IV every 12 hours) or methylprednisolone (16 to 20 mg IV every eight hours) without any delay and broad spectrum antibiotics. These patients should be followed up closely with vital signs and physical examination every four to six hours and should be evaluated in the next 72 hours for any clinical signs of improvement. If patients do not respond to initial IV steroid therapy, then they should be referred to surgery department for colectomy. Educational Objective: Patients with toxic megacolon should be treated with aggressive intravenous steroid therapy for the initial 72 hours before considering for colectomy References: ]]
Approved	Approved::Yes
Keyword	[[WBRKeyword::Ulcerative colitis]], [[WBRKeyword::Inflammatory bowel disease]], [[WBRKeyword::toxic megacolon]]
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::