Findings suggestive of sever Ulcerative colitis :

Pulse  more than 100 bpm

Fever of more than 38 C.

Albumin of less than 30 g/L

CRP more than 45 mg/L.

Bowels open 9 – 10 times during the first 24 hours.

Abdominal X ray shows : Toxic megacolon , mucosal islands and dilated small bowel on radiograph.

MANAGEMENT :

Provide initial resuscitation

ABC / Airway , Breathing and circulation.

INFECTIVE COLITIS :

This should be considered in all cases of acute colitis.

If the patient is very ill and infection cannot be excluded ,it is safer to treat emoerically with combination of antibiotics such as ciprofloxacin and Metronidazole.

This will cover most potential pathogens such as Amoebae and Clostridium difficile.

PSEUDOMEMBRANOUS ENTEROCOLITIS :

This is usually seen inprolonged use of antibiotics espcisally third generation Cephalosporins.

It should be treated with Metronidazole ( iv or PO ) or vancomycin PO after sigmoidoscopy and rectal biopsy has been performed.

And stool has been sent for C. difficile toxin.

INFLAMMATORY BOWEL DISEASE:

A moderate or severe exacerbation should be treated with systemic steroids eg Methylprednisolone 80 – 120 mg intravenously given in to divided doses.

Less severe exacerbations eg those limited to the rectum  should be masnaged with rectsal steroid preparation  with or without smaller dose of oral or intravenous steroids.

5 ASA / Aminosalicylic acid products  also have a role in acute attack.

In patients with known IBD , early involvement of colorectal surgical; team is important.

Don’t wait till evidence of GI perforation or toxic megacolon becomes apparent.

BLOODY DIARRHEA : INVESTIGATIONS

 INVESTIGATIONS :

FULL BLOOD COUNT:

Anemia , may present acutely or may be present in chronic pathology such as incompletely treated IBD / Inflammatory Bowel Disease\

Microcytic hypochromic anemia will beseen in Irean deficiency anemia and  may be suggestive of blood loss.

Megaloblastic anemia is seen in malabsorption syndrome and Alcohol excess.

A raised white cell count suggest bacterial sepsis.

Also Look for Liver function  tests : Serum Bilirubin, ALT and ALPAse / Alkaline Phosphatase.

Electrolytes and Renal function Tests should also be assessed.

Serum albumin levels should be checked.

Less than 30 g/L suggests severe IBD and malnutrition.

Inflammatory markers include CRP and White cell count and should be checked.

Stool should be sent for Microscopic examination , Culture and Sensitivity.

Stool cultures for Clostridium difficile toxins is important as well.

Blood cultures and sensitivity should also be sent  depending upon clinical picture of thepatient.

X-rays / Radiology :

An erect X-ray of abdomen to include both hemi-diaphragms is important to exclude GI perforation.

A supine X ray should be taken to exclude Toxic megacolon of gut.And to look for mucosal islands and small bowle dilatation.

These are suggestive of adverse prognostic signs in IBD / Inflammatory Bowel Disease

Sigmoidoscopy :

This should be performed after an X ray has been performed.

This is because introduction of air during the procdure can produce a picture very similar to Toxic megacolon / dilatation of the gut.

Normal rectal mucose excludes active ulcerative colitis

Inflammed rectal mucose can be seen in any form of severe diarrhea.

The mucosal appearance of Clostridium difficile toxin varies.

Afherent yellow white plaques / pseudo membranes is characteristic.

A rectal biopsy if indicated should be taken well below the peritoneal reflection ie within 10 cm of the anal margin.

BLOODY DIARRHOEA : CLINICAL EXAMINATION

 CLINICAL EXAMINATION :

Assess the overall condition of the patient.

Also assess the circulation status : Blood pressure, Pulse and Temperature.

In case of Bloody Diarrhoea, note the following :

General Features :

Fever

Nutritional status

Presence of anemia ?

Abdomen : 

Pain

DISTENSION

Presence of guarding / rigidity / Peritonism

Presence / absence / sluggish bowel sounds

DRE / Digital rectal examination :

Any perineal changes ? Skin changes ? Fistulae suggestive of crohns disease ?

Palpation for rectal masses , 

Stool chart , record for malena or frank blood?

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Bloody Diarrhea : Precipitating factors and Past Medical History

 Precipitating Factors :

Consider infectious causes :

Has the patient eaten any food that she thinks may have been contaminated or infected ?

Has anyone else she knows had a similar problem?

Has she been abroad recently ?

Clues to specific intestinal infections in patients presenting with diarrhea is shown in the Table below :

Ask about medications :

Has she taken any antibiotics recently that predisposed to C . Difficile?

Has she taken NSAIDS : These are potent causes of colonic irritation and bloody diarrhea.

Other history

Past Medical History

Any past diseases of Bowel  problems ?

Could this be  a flare up of Inflammatory Bowel Disease ?

Could this be a result of post radiotherapy / Radiation colitis ( can cause bleeding from bowel )?

Any past history of bowel surgery ?

Any pother bowel pathology >?

In elderly arteriopath , sudden onset of pain in abdomen and bloody diarrhea can be due to ischaemic coloitis .

In case of diagnosis is not apparent , taking a detailed sexual history to exclude STI and HIV may be necessary.

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