Protocol for the management of acute severe ulcerative colitis in children Introduction: Paediatric UC is severe and more extensive than adult onset UC with 6-8% presenting as pancolitis (1,2) Within five years from diagnosis a significantly higher percentage of patients with childhood onset UC are admitted to emergency units for acute severe colitis, compared to adult onset disease (1,3,4) More children fail intravenous steroids during an acute severe episode (,6) Consequently, this translates into higher colectomy rates in children compared to adult UC populations. It is therefore important to promptly diagnose, initiate treatment and monitor progress during an acute UC flare up. Purpose To deliver standardised/evidenced based practice for all patients admitted with severe Ulcerative Colitis in keeping with current guidelines and IBD standards. These guidelines are intended to assist management of acute severe UC in first 24-72 hours of presentation. Subsequent management needs to be individualised depending on the clinical improvement and not covered in this document 9. Criteria for Inclusion This protocol apply to those patients who meet the following criteria Patient that have confirmed diagnosis of UC Patient suspected to have a severe flare by Truelove & Witts (7) Classification Score. Six bloody stools associated with one or more further activity within the severe category. Activity Mild Moderate Severe No Bloody Stools per day <4 4-6 >6 Temp Afebrile Intermediate >37.8 Heart Rate Normal Intermediate >9 Haemoglobin (g/dl) >11 1.-11 <1. ESR (mm/h) <2 2-3 >3 Title: Protocol for the management of acute severe ulcerative colitis in children Last reviewed: July 21
Assessment In addition to usual clinical assessment of an acutely unwell child, it is important to look for following points History Frequency of stooling, stool consistency, blood in stools, nocturnal stools, weight loss, abdominal pain, limitation of activity to calculate Paediatric Ulcerative Colitis Activity Index (PUCAI) which is only specific for ulcerative colitis and not Crohn s disease 8. Check doses of current medications and patient compliance Examination Look for vital signs tachycardia, anaemia, jaundice, dehydration. Abdominal tenderness (Toxic megacolon) Investigations 1. Send stool mc/s (2 samples) and stool for Cl Diff, Faecal calprotectin 2. Blood tests (FBC, Biochemistry including LFTs, CRP, amylase, Alpha 1 acid glycoprotein/esr). Consider sending Azathioprine metabolites (6TGN/6MMPN) if poor compliance is suspected 3. Request abdominal x ray (AXR) to look for toxic megacolon. Repeat AXR should be dictated by the initial AXR and condition Toxic megacolon - Defined as >.cms diameter transverse colon or > 9cms caecum. If present on admission, an urgent surgical referral must be made and commenced on IV antibiotics (cefuroxime and metronidazole). 24-48 hours of intensive medical therapy may be considered provided patient is sufficiently stable, but a failure to respond by 48 hours, or development of further dilatation during medical therapy mandates consideration of colectomy. Management 1. Calculate PUCAI score (see table 1) and monitor daily to monitor progress. 2. Start methyl prednisolone 1-1. mg per kilogram (max 6 mg) in 2 divided doses. 3. Consider IV antibiotics (as above) if febrile/ infection suspected or likely to need colectomy. 4. Monitor daily PUCAI score. Consider IV fluids if clinically dehydrated. 6. Consider surgical review if AXR suggestive of toxic megacolon 7. Discuss with Paediatric Gastroenterology Consultant on service at Leicester Royal Infirmary (LRI) at earliest opportunity via switchboard. 8. Consider transfer to LRI if clinically indicated. Please note this protocol is only intended for patients with acute severe UC and not for those who have mild to moderate disease. Please discuss with senior colleagues for advice. Title: Protocol for the management of acute severe ulcerative colitis in children Last reviewed: July 21
Table 1: PAEDIATRIC ULCERATIVE COLITIS INDEX (PUCAI) Name/DOB: Date: (1) Abdominal pain No pain Pain can be ignored Pain cannot be ignored (2) Rectal bleeding None Small amount in <% stools Small amount with most stools Large amount (>% stool) (3) Stool consistency of most stools Formed Partially formed Completely unformed (4) Number of stools per 24h -2 3-6-8 >8 () Nocturnal stools (any episode causing wakening) No Yes (6) Activity level No limitation of activity Occasional limitation of activity Points 1 1 2 3 1 1 1 1 1 Title: Protocol for the management of acute severe ulcerative colitis in children Last reviewed: July 21
Severe restricted activity SUM OF PUCAI (-8) Figure 2: Treatment algorithm for acute severe UC (8) Title: Protocol for the management of acute severe ulcerative colitis in children Last reviewed: July 21
Title: Protocol for the management of acute severe ulcerative colitis in children Last reviewed: July 21
References: 1. Lev-Tzion R, Turner D. Is pediatric IBD treatment different than in adults? Minerva Gastroenterol Dietol 212;8:137. 2. Van Limbergen J, Russell RK, Drummond HE, Aldhous MC, Round NK, et al. Definition of phenotypic characteristics of childhood-onset inflammatory bowel disease. Gastroenterology 28;13:1114 22. 3. Turner D, Walsh CM, Benchimol EI, Mann EH, Thomas KE, Chow C, et al. Severe paediatric ulcerative colitis: incidence, outcomes and optimal timing for second-line therapy. Gut 28;7:331 8. 4. Dinesen LC, Walsh AJ, Protic MN, Heap G, Cummings F, Warren BF, et al. The pattern and outcome of acute severe colitis J Crohns Colitis 21;4:431 7.. Turner D, Walsh CM, Steinhart AH, Griffiths AM. Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a meta-regression. Clin Gastroenterol Hepatol 27;:13 1. 6. Turner D, Griffiths AM. Acute severe ulcerative colitis in children: a systematic review. Inflamm Bowel Dis 211;17:44 9. 7. Truelove S C, Witts L. Cortisone in ulcerative colitis: final report on a therapeutic trial. BMJ. 19;2:141 148 8. D Turner et al, Am J Gastroenterol. 211 Apr;16(4):74-88. Epub 211 Jan 11 9. Management of Pediatric Ulcerative Colitis: Joint ECCO and ESPGHAN Evidence-based Consensus Guidelines. JPGN Volume, Number 3, September 212 Title: Protocol for the management of acute severe ulcerative colitis in children Last reviewed: July 21