WEBVTT 1 00:00:10.100 --> 00:00:15.200 Hi everyone. So my topic today point of discussion is ulcerative 2 00:00:15.200 --> 00:00:20.400 colitis. So I thought the audience would be more of 3 00:00:20.400 --> 00:00:25.600 MD internal medicine post MD medicine or first year of PMs gastroenterology 4 00:00:25.600 --> 00:00:30.400 students. So I am going to discuss at that level basics of 5 00:00:30.400 --> 00:00:35.200 ulcerative colitis diagnosis and management. And just again introduce let me introduce 6 00:00:35.200 --> 00:00:39.500 myself. I am Gopi Srikant. So I did my MD from PGI 7 00:00:39.600 --> 00:00:45.100 Chandigarh and I did my DM and so fellowship 8 00:00:45.100 --> 00:00:48.500 from AIIMS New Delhi and worked as a faculty there before moving 9 00:00:48.500 --> 00:00:53.300 to Hyderabad and I currently work in Yashoda Hitech City. So inflammatory 10 00:00:53.300 --> 00:00:58.400 bowel diseases it is a kind of autoimmune disorder where our immunity 11 00:00:58.400 --> 00:01:03.100 altered immunity acts on the gut itself and causes ulcers in the 12 00:01:03.200 --> 00:01:08.400 intestine. So this inflammatory bowel diseases can be of three kinds. 13 00:01:08.900 --> 00:01:13.900 One is ulcerative colitis where predominantly the colon is affected and second 14 00:01:13.900 --> 00:01:18.900 is Crohn's disease where small bowel and 15 00:01:18.900 --> 00:01:23.100 large bowel can be affected and indeterminate colitis where you cannot differentiate 16 00:01:23.100 --> 00:01:27.400 between ulcerative colitis and Crohn's disease. So let me in few slides 17 00:01:27.400 --> 00:01:31.900 I will discuss about the pathophysiology. So the pathophysiology of inflammatory bowel 18 00:01:31.900 --> 00:01:37.100 disease is predominantly because of the three reasons. One 19 00:01:37.200 --> 00:01:42.100 a patient has genetic susceptibility per se and many genetic studies have 20 00:01:42.100 --> 00:01:47.100 shown that people like population in a given 21 00:01:47.100 --> 00:01:53.400 population people with specific genetic loci 22 00:01:54.000 --> 00:01:58.600 are more susceptible to IBD. And when such genetically susceptible person gets 23 00:01:58.600 --> 00:02:03.000 exposed to environmental changes and altered gut microbiota it leads to an 24 00:02:03.000 --> 00:02:08.900 immune dysregulation leading to ulcerations of the GI tract. So 25 00:02:08.900 --> 00:02:13.500 this altered microbiota can be due to many environmental changes. So the 26 00:02:13.500 --> 00:02:18.600 westernization of the our lifestyle especially with the diet 27 00:02:19.100 --> 00:02:23.500 like from more of processed food and less of traditional diets and 28 00:02:23.500 --> 00:02:29.100 more of saturated fats and sugars these can leads to increased 29 00:02:29.100 --> 00:02:34.200 risk of IBD. So because 30 00:02:34.200 --> 00:02:38.600 of this changes there will be altered immunity, immune dysregulation. Because of 31 00:02:38.600 --> 00:02:43.700 the immune dysregulation because of immune dysregulation 32 00:02:44.000 --> 00:02:49.000 what happens is the immunity immune cells attack the intestinal 33 00:02:49.000 --> 00:02:54.100 barrier and then lead there will be infiltration of the both microbiota 34 00:02:54.100 --> 00:02:58.700 and also the immune cells into the submucosa and it affects the 35 00:03:00.000 --> 00:03:04.200 intestinal tract. So let me start with a case series case study 36 00:03:04.200 --> 00:03:09.300 a what 45 year old male presented with intermittent episodes 37 00:03:09.300 --> 00:03:13.400 of bloody diarrhea with colicky abdominal pain for the last six months. 38 00:03:14.000 --> 00:03:17.700 The episodes were recurrent and he has also has urgency and tenesmus. 39 00:03:18.300 --> 00:03:23.500 Why these are important? A tenesmus means the pain while passing stool 40 00:03:24.400 --> 00:03:27.700 and urgency means the patient wants to rush to the washroom and 41 00:03:27.700 --> 00:03:31.400 they cannot wait for five minutes one day starts to have the 42 00:03:31.400 --> 00:03:35.900 advance they start to have urge to pass stool. So the why 43 00:03:35.900 --> 00:03:41.300 these two are important means whenever there is a rectal involved movement 44 00:03:41.300 --> 00:03:44.400 because of any pathology it can be infectious, it can be ulcerative 45 00:03:44.400 --> 00:03:48.600 colitis. It leads to this rectal symptoms of urgency and tenesmus. So 46 00:03:48.600 --> 00:03:51.700 he was admitted with persistent symptoms. So first our doubt whenever a 47 00:03:51.700 --> 00:03:55.400 patients present come to us with diarrhea is is it functional or 48 00:03:55.400 --> 00:03:59.400 is it organic or is it acute or is it chronic? Is 49 00:03:59.400 --> 00:04:02.700 it small diarrhea is the pathology is in small bowel or the 50 00:04:02.700 --> 00:04:07.400 pathology is in large bowel? These are our doubts. And also classification 51 00:04:07.400 --> 00:04:12.400 of diarrhea helps us in coming to a differential diagnosis. For example 52 00:04:12.400 --> 00:04:16.900 if the diet diarrhea duration is less than two weeks it is 53 00:04:16.900 --> 00:04:19.400 called acute diarrhea. If it is more than to four weeks it 54 00:04:19.400 --> 00:04:23.700 is called chronic diarrhea. Most of the infectious diarrheas are less than 55 00:04:23.700 --> 00:04:26.900 two weeks and most of the diarrheas more than four weeks are 56 00:04:26.900 --> 00:04:31.200 non-infectious. So this in this way it help if the diarrhea duration 57 00:04:31.200 --> 00:04:35.400 is between two to four weeks then it's called persistent diarrhea and 58 00:04:35.400 --> 00:04:40.400 often causes can be parasitic or non-infective causes. So how 59 00:04:40.400 --> 00:04:46.400 can we say if the diarrhea is functional or organic? Organic specifically 60 00:04:46.400 --> 00:04:51.500 if there is any any nocturnal once the patient sleeps and patient 61 00:04:51.500 --> 00:04:53.500 needs to get up at the night to pass through then it 62 00:04:53.500 --> 00:04:57.000 is organic or there can be blood or it can be incontinent, 63 00:04:57.200 --> 00:05:01.500 it can be weight loss and any features of dehydration. So these 64 00:05:01.500 --> 00:05:06.000 are organic. In this patient the patient has bloody diarrhea. So it 65 00:05:06.000 --> 00:05:09.600 is an organic cause. Now comes and it is of six months 66 00:05:09.600 --> 00:05:14.400 duration so it is chronic diarrhea. So chronic organic diarrhea. So my 67 00:05:14.400 --> 00:05:18.100 our question is is it the is the pathology is in small 68 00:05:18.100 --> 00:05:23.600 bowel or is the pathology in the large bowel? So in the 69 00:05:23.600 --> 00:05:28.800 features in the large bowel so just concentrate on this. if 70 00:05:28.800 --> 00:05:32.300 the pathology is in large bowel so there will be secretions in 71 00:05:32.300 --> 00:05:36.800 the large bowel and the large bowel tries to evacuate whatever lower 72 00:05:36.800 --> 00:05:41.000 stool is there in the rectum. So the volume will be less 73 00:05:41.700 --> 00:05:45.200 in the in the large intestine in the small intestine pathology the 74 00:05:45.200 --> 00:05:49.200 volume will be larger. And also rectal symptoms as I told you 75 00:05:49.200 --> 00:05:54.400 urgency, tenesmus, mucus are seen in large bowel diarrhea. And 76 00:05:54.500 --> 00:05:59.600 other because small intestine is the 77 00:05:59.900 --> 00:06:05.100 site of absorption, carbohydrate absorption, protein absorption and fat absorption. So malabsorption 78 00:06:05.100 --> 00:06:08.400 of protein, malabsorption of carbohydrate, malabsorption of fat can occur in small 79 00:06:08.400 --> 00:06:12.900 bowel small bowel type of diarrhea. So now we are clear that 80 00:06:12.900 --> 00:06:15.500 it is a large bowel of diarrhea because there is small volume, 81 00:06:15.500 --> 00:06:19.100 bloody diarrhea, urgency, tenesmus are there. It's a large bowel type of 82 00:06:19.100 --> 00:06:23.400 diarrhea and it is a chronic diarrhea. It is a non-functional. So 83 00:06:23.400 --> 00:06:27.600 organic so with blood or without blood with blood we have differential 84 00:06:27.600 --> 00:06:32.600 diagnosis of three. One is inflammatory bowel disease 85 00:06:33.000 --> 00:06:35.500 and chronic can be TB in India. It can be present in 86 00:06:35.500 --> 00:06:39.200 any way and third is carcinoma colon can present with large bowel 87 00:06:39.200 --> 00:06:43.500 of diarrhea. These three will be the differential diagnosis. So how do 88 00:06:43.500 --> 00:06:47.700 you go ahead? It's the colonoscopy or sigmoidoscopy that gives the diagnosis. 89 00:06:48.500 --> 00:06:51.600 So now coming to how to label a patient has having ulcerative 90 00:06:51.600 --> 00:06:55.400 colitis. So what is there any gold standard? For example if a 91 00:06:55.400 --> 00:06:59.700 patient comes to us with fever we do some malaria antigen test, 92 00:06:59.700 --> 00:07:03.100 peripheral smear and if you see the parasite of malaria in the 93 00:07:03.100 --> 00:07:08.100 blood through antigen or microscopy you say that the 94 00:07:08.100 --> 00:07:12.300 patient has diagnosis of malaria. It's the gold standard. In such a 95 00:07:12.300 --> 00:07:15.400 way do you have any gold and also like example for example 96 00:07:15.400 --> 00:07:18.100 if a patient has cough and you tested the sputum it is 97 00:07:18.100 --> 00:07:21.000 AFB positive you say that it is TB. It is gold standard. 98 00:07:21.300 --> 00:07:25.000 In the same way does we do we have any test to 99 00:07:25.100 --> 00:07:30.000 for a gold standard diagnosis of ulcerative colitis? No. Because it is 100 00:07:30.000 --> 00:07:36.000 an amalgam of multiple features where you need to consider clinical, laboratory, 101 00:07:36.100 --> 00:07:41.300 imaging, endoscopic and histopathology. The 102 00:07:41.300 --> 00:07:45.800 five you need to see you need to combine the all these 103 00:07:45.800 --> 00:07:49.400 five features together to label a patient as ulcerative colitis and the 104 00:07:49.400 --> 00:07:54.400 same works for Crohn's disease. To reiterate to label a 105 00:07:54.400 --> 00:07:59.000 patient with inflammatory bowel diseases you need to consider all the five 106 00:07:59.500 --> 00:08:04.600 features clinical, laboratory, imaging, endoscopic 107 00:08:04.600 --> 00:08:08.500 and histopathology. And in all cases infectious causes will be ruled out. 108 00:08:09.000 --> 00:08:14.400 So once so once you label a patient as ulcerative 109 00:08:14.400 --> 00:08:18.500 colitis now it is a ulcerations in the colon. We need to 110 00:08:18.500 --> 00:08:23.900 know to what extent the pathology is involved. Like for we 111 00:08:23.900 --> 00:08:27.000 can say that it is it's a there's a classification called Montreal 112 00:08:27.000 --> 00:08:31.700 classification where it is called E1, E2, E3. E1 is proctitis that 113 00:08:31.700 --> 00:08:36.500 is only the rectum distal 15 centimeters of large intestine is involved. 114 00:08:37.000 --> 00:08:42.400 E2 disease if it is involvement of rectum till 115 00:08:42.400 --> 00:08:48.600 splenic flexure or if it is beyond splenic flexure it 116 00:08:48.600 --> 00:08:53.000 is called E3 disease extensive. It is based on the endo colonoscopy 117 00:08:53.000 --> 00:08:57.500 or sigmoidoscopy. You cannot tell the complete extent with sigmoidoscopy because you 118 00:08:57.500 --> 00:09:00.200 need to go beyond splenic flexure to label the extent of the 119 00:09:00.200 --> 00:09:05.600 disease. So once you go there you will label. So and also 120 00:09:05.900 --> 00:09:10.500 because I'm not going into the endoscopic details because of the audience. 121 00:09:12.200 --> 00:09:16.200 So next when you take a biopsy what are the histological features? 122 00:09:16.800 --> 00:09:22.800 So one is because the chronic inflammation causing chronic 123 00:09:22.800 --> 00:09:28.000 injury to the colonic mucosa. What happens is there will be 124 00:09:28.900 --> 00:09:33.200 react like destruction of the crypt architecture. There will be crypts in 125 00:09:33.200 --> 00:09:37.800 the colonic mucosa. The architecture the normal will be distracted. There will 126 00:09:37.800 --> 00:09:43.200 be crypt architectural distortion and also the reactionary blast basal 127 00:09:43.200 --> 00:09:46.700 plasma cytosis that is plasma cells get deposited at the base of 128 00:09:46.700 --> 00:09:51.700 the submucosa. So next once you labeled it as ulcerative 129 00:09:51.700 --> 00:09:56.700 colitis to treat any disease you need to know know 130 00:09:56.700 --> 00:09:59.900 the severity of the disease. Whether you need to admit the patient 131 00:10:00.000 --> 00:10:02.400 or you want to treat the patient on OPD basis. If you 132 00:10:02.400 --> 00:10:05.300 want to treat the patient on OPD basis you should should you 133 00:10:05.300 --> 00:10:09.100 give the low potency drugs or high potency drugs? So to treat 134 00:10:09.100 --> 00:10:14.000 any disease you need to know the severity of the disease. So 135 00:10:14.000 --> 00:10:18.900 for ulcerative colitis the severity can be mentioned by in by we 136 00:10:18.900 --> 00:10:23.500 have scoring systems of Truelove and Witts criteria and Mayo score. So 137 00:10:23.500 --> 00:10:26.300 you can label it as mild to moderate disease or moderate to 138 00:10:26.300 --> 00:10:31.400 severe disease. So coming to Truelove 139 00:10:31.400 --> 00:10:35.800 and Witts score it has one symptom, two signs and three investigations. 140 00:10:36.100 --> 00:10:39.100 One symptom is bloody diarrhea. Is it more than or equal to 141 00:10:39.100 --> 00:10:43.700 six or less than four? Next signs are two pulse and temperature. 142 00:10:43.800 --> 00:10:46.900 Check the temperature if it is more than 100° Fahrenheit it is 143 00:10:47.000 --> 00:10:51.700 severe category or it is tachycardia it is severe category. And next 144 00:10:51.700 --> 00:10:56.700 is three investigations that is hemoglobin, CRP, ESR. So hemoglobin 145 00:10:56.700 --> 00:11:02.200 less than 10.5 severe disease if there is no underlying anemia and 146 00:11:02.200 --> 00:11:07.300 CRP or ESR more than 30. And Mayo 147 00:11:07.300 --> 00:11:11.300 score it is a commonly used score. It has four like four 148 00:11:11.300 --> 00:11:16.300 subgroups. Three are clinical and one is endoscopy. Clinical work first 149 00:11:16.300 --> 00:11:22.000 is stool frequency. You need to know the stool frequency. Here 150 00:11:22.100 --> 00:11:25.500 it is how many times what is you need to ask the 151 00:11:25.500 --> 00:11:28.800 patient for him what is his baseline stool frequency. For if the 152 00:11:28.800 --> 00:11:33.800 baseline when he's normal if the stool baseline frequency is two. Now 153 00:11:33.800 --> 00:11:39.500 he has four. Then it is two more than normal 154 00:11:39.500 --> 00:11:42.600 then the score is one. So how many times more than the 155 00:11:42.600 --> 00:11:47.100 baseline you need to know accordingly stool frequency is calculated and based 156 00:11:47.100 --> 00:11:49.700 on you can give the score of zero, one, two, three and 157 00:11:49.700 --> 00:11:52.400 then you should ask for rectal bleeding. How severe is the rectal 158 00:11:52.400 --> 00:11:57.100 bleeding? Is it just streaks of blood or obvious blood or patient 159 00:11:57.100 --> 00:12:00.200 is not passing stool at all only he's passing blood then it 160 00:12:00.200 --> 00:12:05.200 is stage three. And next is sigmoidoscopy or colonoscopic findings. 161 00:12:06.400 --> 00:12:10.600 This will be like normal, mild disease, moderate disease and severe disease. 162 00:12:11.200 --> 00:12:15.600 And then physician's global assessment. What is your assessment? If how is 163 00:12:15.600 --> 00:12:19.400 your assessment of the patient? Like easy are you feeling it's mild, 164 00:12:19.400 --> 00:12:24.700 moderate or severe based on this score is given. 165 00:12:25.100 --> 00:12:28.000 So for it is severity it is called severe if it is 166 00:12:28.000 --> 00:12:34.100 more than 10. So do 167 00:12:34.100 --> 00:12:38.200 you do test any imaging? Often ulcerative colitis patient doesn't require any 168 00:12:38.200 --> 00:12:42.000 imaging only when the patient present with severe ulcerative colitis you do 169 00:12:42.000 --> 00:12:45.500 an X-ray. If the patient to rule out any toxic megacolon that 170 00:12:45.500 --> 00:12:50.200 which is dilatation of transverse colon to more than 6 cm on 171 00:12:50.200 --> 00:12:55.000 supine X-ray. And if the patient has acute abdomen and you are 172 00:12:55.000 --> 00:13:00.000 if you are suspecting perforation then a CT may be 173 00:13:00.000 --> 00:13:03.900 merited. And sometimes if you have any diagnostic dilemma to differentiate it 174 00:13:03.900 --> 00:13:08.400 from Crohn's disease you may do a cross-sectional imaging. Are there any 175 00:13:08.400 --> 00:13:13.800 role of serology like but there is no role of serology in 176 00:13:13.900 --> 00:13:18.400 diagnosis of ulcerative colitis. And there are few other investigations like fecal 177 00:13:18.400 --> 00:13:23.900 calprotectin. It is an calprotectin secreted from neutrophils 178 00:13:24.300 --> 00:13:29.400 that comes through the ulcerations into the stool. So it can predict 179 00:13:29.500 --> 00:13:34.900 the activity of the disease 180 00:13:35.200 --> 00:13:38.600 without for example if a patient doesn't want to undergo sigmoidoscopy you 181 00:13:38.600 --> 00:13:43.600 can monitor the patient with the fecal calprotectin levels. So 182 00:13:44.200 --> 00:13:47.600 and you do you need to differentiate it from Crohn's disease? Yes. 183 00:13:48.600 --> 00:13:53.300 For few reasons because some drugs don't act in ulcerative colitis and 184 00:13:53.300 --> 00:13:58.100 some don't act in Crohn's disease. For example cyclosporine and and tofacitinib 185 00:13:58.100 --> 00:14:03.600 don't act in Crohn's disease and methotrexate don't act in ulcerative 186 00:14:03.600 --> 00:14:08.800 colitis and also there will be if there is any severe 187 00:14:08.800 --> 00:14:13.100 ulcerative colitis the severe colitis requiring surgery there will be dilemma for 188 00:14:13.100 --> 00:14:15.900 the surgeon what to do based on whether it's ulcerative colitis or 189 00:14:15.900 --> 00:14:21.000 Crohn's disease. Next is sometimes the second patient can present with 190 00:14:21.000 --> 00:14:24.300 acute diarrhea. For example if a patient has ulcerative colitis in the 191 00:14:24.300 --> 00:14:29.100 first episode the duration will be acute diarrhea only two weeks duration. 192 00:14:29.100 --> 00:14:33.700 Then how to differentiate such patient of first presentation of ulcerative colitis 193 00:14:33.700 --> 00:14:38.300 from infectious colitis. So for example this young male presented with increased 194 00:14:38.300 --> 00:14:43.400 stool frequency with that for the last two weeks. 195 00:14:44.100 --> 00:14:48.600 And now here comes the role of biopsy. Biopsy you can see 196 00:14:48.600 --> 00:14:52.900 basal plasma cytosis which I have mentioned earlier. It is seen even 197 00:14:52.900 --> 00:14:55.700 developed within two weeks of the onset of the disease and it 198 00:14:55.700 --> 00:14:59.500 is very specific for ulcerative colitis. The crypt distortion which I have 199 00:14:59.500 --> 00:15:03.800 told you may occur after two weeks. So please ask your pathologist 200 00:15:03.800 --> 00:15:07.600 to look for this basal plasma cytosis at the same time rule 201 00:15:07.600 --> 00:15:13.100 out infectious causes like amebiasis and 202 00:15:13.300 --> 00:15:18.300 E. coli coli Shigella other thing with stool culture 203 00:15:18.800 --> 00:15:23.300 and some sometime what you can do is if the in limited 204 00:15:23.300 --> 00:15:26.100 settings if you don't if you can't test for this you can 205 00:15:26.100 --> 00:15:31.200 give empirical antibiotics. So if the patient resolves then 206 00:15:31.200 --> 00:15:36.200 just if you have still suspicion of ulcerative colitis just repeat sigmoidoscopy 207 00:15:36.200 --> 00:15:39.500 after two to three weeks. If still ulcerations are present then it 208 00:15:39.500 --> 00:15:43.000 is ulcerative colitis. If there is complete healing of mucosa with antibiotics 209 00:15:43.000 --> 00:15:48.000 then it is infectious colitis. And next whenever a patient with 210 00:15:48.200 --> 00:15:53.400 once you diagnose a patient of colitis in 211 00:15:53.400 --> 00:15:57.700 clinical please do ask for extra intestinal manifestations. Although the pathology is 212 00:15:57.700 --> 00:16:01.500 more symptoms are predominantly towards the because of ulcerations in the large 213 00:16:01.500 --> 00:16:07.000 colon some patients can have extra intestinal manifestations and the common common 214 00:16:07.000 --> 00:16:10.900 things are these there's musculoskeletal that is axial arthropathies, low back ache, 215 00:16:12.000 --> 00:16:17.500 arthritis, polyarthritis and there can be in mucocutaneous 216 00:16:17.500 --> 00:16:22.500 involvement like recurrent oral ulcers and skin involvement like erythema 217 00:16:22.500 --> 00:16:28.000 nodosum. These are the common other that are rare. So 218 00:16:28.000 --> 00:16:31.900 just to summarize what we have read till now. So take the 219 00:16:31.900 --> 00:16:35.600 history, label whether it is a chronic diarrhea or acute diarrhea, is 220 00:16:35.600 --> 00:16:39.000 it large bowel of diarrhea, large bowel diarrhea and ask for extra 221 00:16:39.000 --> 00:16:42.900 intestinal manifestations. Are there any recurrent oral ulcers, any redness of eyes 222 00:16:42.900 --> 00:16:47.600 for scleritis, any joint pains or back ache, any skin lesions? These 223 00:16:47.600 --> 00:16:53.200 are the common extra intestinal manifestations. Then you advise a colonoscopy 224 00:16:53.200 --> 00:16:57.600 or sigmoidoscopy and see to the extent of involvement of the disease, 225 00:16:57.900 --> 00:17:01.700 take biopsies and also give us and assess the severity of the 226 00:17:01.700 --> 00:17:06.700 disease by Mayo score and 227 00:17:06.700 --> 00:17:11.800 ask the pathologist to look for specifically crypt distortion blast basal plasma 228 00:17:11.800 --> 00:17:15.900 cytosis and assess the disease severity. So now I diagnose it as 229 00:17:15.900 --> 00:17:19.800 ulcerative colitis. If I didn't do a colonoscopy I cannot know the 230 00:17:20.000 --> 00:17:24.300 disease extent and it can be moderate severity and extra intestinal manifestations 231 00:17:24.300 --> 00:17:29.000 are not there. Second thing is some infections as I told you 232 00:17:29.000 --> 00:17:32.800 sometimes in ulcerative colitis CMV infection can be there and Clostridioides difficile 233 00:17:32.800 --> 00:17:39.100 infection is there. Especially these two have to be ruled 234 00:17:39.100 --> 00:17:43.200 out whenever there is a case of known case of ulcerative colitis 235 00:17:43.200 --> 00:17:46.700 who is on treatment and presented with worsening of symptoms on treatment. 236 00:17:47.000 --> 00:17:50.000 So CMV you go there you see deep ulcers, you take a 237 00:17:50.000 --> 00:17:55.100 biopsy and send it for CMV PCR load. Or if 238 00:17:55.100 --> 00:17:58.900 you don't have PCR thing ask the pathologist to look for intranuclear 239 00:17:59.500 --> 00:18:04.700 inclusion bodies. And if it is present you treat with IV ganciclovir 240 00:18:04.700 --> 00:18:09.700 or And Clostridioides difficile you 241 00:18:09.700 --> 00:18:15.500 need to do two step test. One is highly sensitive to 242 00:18:15.500 --> 00:18:18.500 glutamate dehydrogenase or PCR and if it is positive you need to 243 00:18:18.500 --> 00:18:23.300 test for toxin assay. So now coming to treatment of ulcerative colitis. 244 00:18:24.400 --> 00:18:29.600 So like if there are any doubts till the diagnosis 245 00:18:29.600 --> 00:18:34.300 we can discuss or we can or shall we continue? Sir we'll 246 00:18:34.300 --> 00:18:38.200 take the questions at end of the session. Okay. So coming to 247 00:18:38.200 --> 00:18:43.100 treatment of ulcerative colitis again let me more of introduce you to 248 00:18:43.100 --> 00:18:48.100 the various drugs in the armamentarium that will be available 249 00:18:51.000 --> 00:18:54.900 available for the management of ulcerative colitis. So let's not go into 250 00:18:54.900 --> 00:18:58.200 the difficult to treat situations. Let us be let us me introduce 251 00:18:58.200 --> 00:19:04.300 you to the basics of drugs and basic treatment. So so 252 00:19:04.300 --> 00:19:09.100 there are many therapies for ulcerative colitis. So usually in ulcerative colitis 253 00:19:09.100 --> 00:19:12.400 they we go for a sequential therapy the like top up therapy. 254 00:19:12.900 --> 00:19:15.900 So what is it is you assess the severity of the disease 255 00:19:15.900 --> 00:19:20.500 mild, moderate, severe based on you go with you choose your drug. 256 00:19:20.800 --> 00:19:27.300 So your drug is so safety is first. So the 257 00:19:27.300 --> 00:19:32.300 mild disease highly safe and more tolerable drug has to be selected. 258 00:19:32.800 --> 00:19:37.500 For example aminosalicylates are the most important drug the basic drug which 259 00:19:37.500 --> 00:19:44.700 we give. Basic 260 00:19:44.700 --> 00:19:48.800 drug which we give here and if it is a moderate disease 261 00:19:48.900 --> 00:19:54.000 then budesonide or prednisone. If still not controlled then other drugs 262 00:19:54.000 --> 00:19:59.400 anti-TNFs other things. So coming to salicylates salicylates 263 00:20:00.500 --> 00:20:06.100 like they act on the colonic mucosa 264 00:20:06.400 --> 00:20:11.300 and they decrease the inflammation. So there are various kinds of aminosalicylates 265 00:20:11.600 --> 00:20:16.800 and of this commonly we use the mesalamine preparations. The sulfasalazine 266 00:20:16.800 --> 00:20:20.200 is the original drug because of the poor tolerance is often not 267 00:20:20.200 --> 00:20:25.600 used. Commonly mesalamine preparations are used that is called mesacol, pentasa, rowasa 268 00:20:25.600 --> 00:20:28.800 these are the things that are commonly used. So these can be 269 00:20:28.800 --> 00:20:33.100 given orally or if the disease is only in the distal colon 270 00:20:33.100 --> 00:20:38.400 you can give it as enema so suppository preparations. 271 00:20:39.600 --> 00:20:44.700 So you need and there are various preparations of these mesalamine. So 272 00:20:44.800 --> 00:20:48.300 and they vary based on the release site. For example if the 273 00:20:48.300 --> 00:20:53.600 patient has predominantly colon of course in ulcerative colitis it's colonic involvement. 274 00:20:53.800 --> 00:20:57.600 So you can use the mesalamine preparations like mesacol and other drugs 275 00:20:58.100 --> 00:21:02.100 and especially in Crohn's where the if the ulcerations are in small 276 00:21:02.100 --> 00:21:06.100 bowel you want to use aminosalicylate then you need to use a 277 00:21:06.100 --> 00:21:09.900 mesalamine that is released in jejunum, ileum and colon also. Then pentasa 278 00:21:09.900 --> 00:21:15.300 is a good drug. For the ulcerative colitis 279 00:21:15.300 --> 00:21:20.700 mesalamine simple preparations can be or sulfasalazine are sufficient. So if 280 00:21:20.700 --> 00:21:24.800 the disease activity is only the rectum like even disease then just 281 00:21:24.800 --> 00:21:29.500 give it as a suppository or so rectal mesalamine suppository will work. 282 00:21:29.900 --> 00:21:34.000 If the disease activity is still sigmoid colon then foam at a 283 00:21:34.000 --> 00:21:39.100 like foams work and if the knees in descending colon then 284 00:21:39.100 --> 00:21:42.500 you can give enemas which can reach up to splenic flexure. But 285 00:21:42.500 --> 00:21:48.100 our enemas don't reach beyond splenic flexure so if for 286 00:21:48.300 --> 00:21:51.200 the involvement of transverse colon and ascending colon you need to give 287 00:21:51.200 --> 00:21:57.000 oral drugs. So next is there's a new one 288 00:21:57.000 --> 00:22:01.600 more drug I want to tell you after aminosalicylate that is budesonide. 289 00:22:02.300 --> 00:22:07.300 So usually steroids are used but steroids have very systemic side effects 290 00:22:07.300 --> 00:22:12.900 like osteoporosis, infection risk, glaucoma and 291 00:22:12.900 --> 00:22:17.800 other and poor glycemic control. So there is another drug called budesonide. 292 00:22:18.300 --> 00:22:24.200 The advantage of budesonide is once 293 00:22:24.200 --> 00:22:28.500 you take a budesonide 90% gets undergoes it acts in the because 294 00:22:28.900 --> 00:22:33.400 the pathology in the colon. It acts in the colon, gets absorbed 295 00:22:33.800 --> 00:22:38.800 and once it leads reaches the liver through mesenteric circulation 90% undergo 296 00:22:38.800 --> 00:22:43.900 first pass metabolism and only 10% reaches the systemic circulation. So with 297 00:22:43.900 --> 00:22:48.600 this drug the systemic side effects will be less compared to prednisone 298 00:22:48.600 --> 00:22:56.200 or methylprednisolone. So but the the 299 00:22:56.200 --> 00:23:00.100 thing is the budesonide cannot reach. It gets absorbed within the stomach 300 00:23:00.100 --> 00:23:05.100 or ileum or small intestine. So a special delivery system like 301 00:23:05.100 --> 00:23:09.600 special preparation is made called MMX. It is multimatrix delivery system where 302 00:23:09.600 --> 00:23:12.700 it doesn't gets dissolved anything in a stomach or other things. It 303 00:23:12.700 --> 00:23:17.600 gets only released in the distal ileum and the colon. Other drugs 304 00:23:17.600 --> 00:23:20.400 second one more drug you need to know that is commonly used 305 00:23:20.400 --> 00:23:25.400 in ulcerative colitis is azathioprine and mercaptopurines. 306 00:23:25.400 --> 00:23:30.800 These are called thiopurines. So 307 00:23:30.900 --> 00:23:36.200 these are basically they inhibit the metabolism in the nucleus, 308 00:23:36.200 --> 00:23:42.700 nucleic acid metabolism, enzyme inhibitors. They are for example and so 309 00:23:42.800 --> 00:23:48.000 these azathioprine is the commonly used drug. So it inhibits the 310 00:23:48.800 --> 00:23:54.500 DNA like synthesis DNA synthesis in the lymphocytes and causes decreases 311 00:23:54.500 --> 00:24:00.800 the altered dysregulated immunity. So 312 00:24:01.000 --> 00:24:06.000 usual dose dose that that is given in 313 00:24:06.300 --> 00:24:09.600 azathioprine is two to 2.5 mg per kg. And what are the 314 00:24:09.600 --> 00:24:15.200 common side effects for leukopenia, cytopenia especially leukopenia, thrombocytopenia, hepatitis, pancreatitis 315 00:24:15.200 --> 00:24:20.400 or GI intolerance. So of all the drugs we have discussed aminosalicylates, 316 00:24:21.200 --> 00:24:26.700 budesonide, thiopurines. So just systemic steroids like prednisone. 317 00:24:27.000 --> 00:24:29.300 So if you if you have a patient of mild to moderate 318 00:24:29.300 --> 00:24:35.900 ascites based on the Mayo score you give oral under topical aminosalicylate 319 00:24:38.500 --> 00:24:43.600 it's based on the disease. And if there is response then so 320 00:24:43.700 --> 00:24:46.400 treatment consists of two parts. One is induction and one is remission, 321 00:24:46.900 --> 00:24:51.200 maintenance of remission, maintenance. Induction is you just treat the ulcers and 322 00:24:51.200 --> 00:24:55.800 to maintain the healing you need to continue maintenance therapy because ulcerative 323 00:24:55.800 --> 00:25:00.000 colitis is a lifelong disease and that you can only treat the 324 00:25:00.130 --> 00:25:03.430 This disease can never cure the disease. So you need to give 325 00:25:03.430 --> 00:25:07.430 induction, control the ulcers, then do give a maintenance thing for the 326 00:25:07.430 --> 00:25:12.830 lifelong thing, lifelong. So one once 327 00:25:12.830 --> 00:25:15.730 you achieve remission that is then that is healing of ulcers, you 328 00:25:15.730 --> 00:25:20.730 continue oral aminosalicylates for maintenance. If there is no response 329 00:25:20.730 --> 00:25:25.930 with aminosalicylates, then you can give budesonide MMX before giving steroids 330 00:25:26.230 --> 00:25:29.930 because the systemic side effects were minimal. If still there is no 331 00:25:29.930 --> 00:25:34.930 response, then you can go for systemic steroids. And important 332 00:25:34.930 --> 00:25:38.830 is whenever you are treating a patient of ulcerative colitis, important is 333 00:25:38.830 --> 00:25:43.130 adherence. Ask the patient to take the drugs regularly and second if 334 00:25:43.130 --> 00:25:48.430 there is distal involved element use suppositories or enema 335 00:25:48.430 --> 00:25:52.630 as and when required and third dose optimization. So for a dose 336 00:25:52.630 --> 00:25:57.730 optimization optimization usually if it is a mesalamine we give 1.2 g 337 00:25:57.830 --> 00:26:02.130 BD, then you can escalate it to 3.6 to 4.8 g per 338 00:26:02.130 --> 00:26:07.230 day. And it does unlike paracetamol which acts immediately takes around two 339 00:26:07.230 --> 00:26:10.630 to four weeks for the drug to act mesalamine. So don't be 340 00:26:10.630 --> 00:26:12.830 in a hurry, you need to wait for two to four weeks 341 00:26:12.930 --> 00:26:16.330 for the complete action to be seen. And also azathioprine dose is 342 00:26:16.330 --> 00:26:21.330 usually 2 mg per kg and you need to wait for 343 00:26:21.330 --> 00:26:23.930 at least three to four months for you to see the action. 344 00:26:24.830 --> 00:26:27.930 So this is the stride therapy. So this is the regarding the 345 00:26:27.930 --> 00:26:32.230 treatment. So this is the stride consensus. So patient has active disease. 346 00:26:32.430 --> 00:26:36.630 Now you have given the treatment, patient symptoms resolved that is diarrhea 347 00:26:36.630 --> 00:26:41.730 resolved and also inflammatory markers CRP got resolved. Then now 348 00:26:41.730 --> 00:26:45.630 the thing is, is there any mucosal healing if but even if 349 00:26:45.630 --> 00:26:48.430 you the symptoms got resolved, there can be some ulceration in the 350 00:26:49.330 --> 00:26:55.430 intestine. But you need to achieve that ulceration healing 351 00:26:55.430 --> 00:26:59.730 also for a long-term goal. So there should be endoscopic healing called 352 00:26:59.730 --> 00:27:03.430 mucosal healing that is a long-term goal. So once you achieve symptomatic 353 00:27:03.830 --> 00:27:07.130 response, you look for inflammatory markers response, you got it and then 354 00:27:07.130 --> 00:27:11.230 look for a mucosal healing. If there is no mucosal healing, whatever 355 00:27:11.230 --> 00:27:15.630 the drugs we discussed like aminosalicylate, azathioprine are not sufficient, you need 356 00:27:15.630 --> 00:27:20.830 to escalate your therapy. So what else we have to offer? So 357 00:27:21.030 --> 00:27:26.330 the predominant molecule uh like pathological molecule in 358 00:27:29.230 --> 00:27:33.030 ulcerative colitis and Crohn's is showman necrosis factor alpha that is TNF 359 00:27:33.330 --> 00:27:38.430 that initiates damage to the and propagates the damage in inflammatory bowel 360 00:27:38.430 --> 00:27:43.630 diseases. So there were molecules, monoclonal antibody molecules against this anti 361 00:27:43.630 --> 00:27:48.630 TNF like against tumor necrosis factor TNF and they 362 00:27:48.630 --> 00:27:53.630 can go trap the TNF and uh make it 363 00:27:53.730 --> 00:27:58.930 dysfunctional and control the inflammation. So 364 00:27:58.930 --> 00:28:03.930 there are many type of antibodies just 365 00:28:03.930 --> 00:28:08.330 because uh for how is the nomenclature to discuss? So like how 366 00:28:08.330 --> 00:28:13.330 a monoclonal antibody is labeled? If it is from mouse, 100% 367 00:28:13.330 --> 00:28:16.030 mouse, it is called OMAb which you don't use now it is. 368 00:28:16.430 --> 00:28:21.230 If it is chimeric that is 65% is human, that is heavy 369 00:28:21.230 --> 00:28:24.130 chain is human and variable portion of murine is called chimeric then 370 00:28:24.130 --> 00:28:28.330 it's called ZMAb. If it is more than 90% is human, that 371 00:28:28.330 --> 00:28:33.330 is heavy chains and only variable parts are of mouse origin then 372 00:28:33.330 --> 00:28:38.330 it is called humanized that is MAb. If 373 00:28:38.330 --> 00:28:41.230 it is 100% human then it is called NMAb. So we have 374 00:28:41.330 --> 00:28:45.930 in the semi infliximab Z this is chimeric infliximab adalimumab it is 375 00:28:45.930 --> 00:28:51.230 humanized. No. And also apart 376 00:28:51.230 --> 00:28:55.530 from this is uh the molecules there is an uh cellular mediated 377 00:28:55.530 --> 00:29:00.230 toxicity in ulcerative colitis and Crohn's disease is also. There are many 378 00:29:00.230 --> 00:29:05.430 kinds of uh cell lines like T cell subsets, TH1, TH2, 379 00:29:05.430 --> 00:29:12.530 TH17, T regulatory cells which got this which gets and 380 00:29:12.730 --> 00:29:17.430 many cytokines are involved in this pathology. So you can target these 381 00:29:17.430 --> 00:29:22.530 cytokines. For example, uh there is uh IL 23 382 00:29:22.530 --> 00:29:27.130 and IL 12 has one common subset of P40. So you can 383 00:29:27.130 --> 00:29:33.130 develop an antibody against this P40 subset and it's called this 384 00:29:33.130 --> 00:29:38.530 antibody acts this antibody 385 00:29:38.530 --> 00:29:46.130 acts against this P40. So you can manage both IL 12 386 00:29:46.130 --> 00:29:52.830 and IL 23 again. Uh just give me a minute. Oh 387 00:29:52.830 --> 00:29:56.030 sorry for the disturbance. And next in the same way we are 388 00:29:56.130 --> 00:30:00.830 able to target two interleukins. In the same way we can can 389 00:30:00.830 --> 00:30:06.030 we target multiple cytokines? So this is called JAK Janus 390 00:30:06.030 --> 00:30:12.930 kinase inhibitors. This is called tofacitinib. So here what 391 00:30:12.930 --> 00:30:17.330 is the action of this JAK kinase? Whenever this cytokine comes and 392 00:30:17.330 --> 00:30:22.630 attaches to this receptor of JAK kinase, it produces activates activates multiple 393 00:30:23.230 --> 00:30:27.030 interleukins production. So if you are able if you can block this 394 00:30:27.030 --> 00:30:32.530 JAK kinase receptor, then you will be able to uh then 395 00:30:32.530 --> 00:30:36.930 you will be able to inhibit these molecules. So then it is 396 00:30:36.930 --> 00:30:40.430 called one of the example is tofacitinib which is commonly used. It 397 00:30:40.430 --> 00:30:44.330 is useful in ulcerative colitis cheaper. What is the advantage of this 398 00:30:46.930 --> 00:30:50.930 this molecule against compared to other antibodies? This molecule is a oral 399 00:30:50.930 --> 00:30:56.230 tablet compared but antibodies are injections cheaper. And because antibodies 400 00:30:56.230 --> 00:31:00.930 are made from mouse models some antibodies they can develop antibodies to 401 00:31:00.930 --> 00:31:06.030 the antibodies. But this tofacitinib doesn't develop antibodies and is it taken. 402 00:31:06.630 --> 00:31:11.530 So next so there if there is a lymphocyte and this goes 403 00:31:11.530 --> 00:31:15.930 to the attaches to the capillary and attaches to the endothelium and 404 00:31:15.930 --> 00:31:21.230 they then undergoes goes to 405 00:31:21.230 --> 00:31:26.230 the tissue infiltration. So can we prevent this uh migration of 406 00:31:26.230 --> 00:31:31.430 this lymphocyte across the endothelium? Yes. So how does it attach? So 407 00:31:31.830 --> 00:31:37.030 these are the integrins. So these are the for example 408 00:31:37.030 --> 00:31:41.130 we have an endothelium this is called MAdCAM. And there is an 409 00:31:41.130 --> 00:31:46.530 alpha 4 beta 7 integrin on the lymphocyte. These receptors get attached 410 00:31:46.630 --> 00:31:52.030 and this helps in transmigration of lymphocytes into the GI tract. So 411 00:31:52.030 --> 00:31:57.130 can we target this receptor so that the lymphocyte 412 00:31:57.130 --> 00:32:01.830 don't enter the submucosa and damage the epithelial cells. So we have 413 00:32:01.830 --> 00:32:06.630 antibodies against this alpha 4 beta 7 called vedolizumab which can prevent 414 00:32:06.630 --> 00:32:12.030 the transmigration. And second thing uh in our body 415 00:32:12.930 --> 00:32:16.730 uh the lymphocytes are produced in lymph nodes. And how do does 416 00:32:16.730 --> 00:32:22.130 these lymphocytes go into the blood system? There is an receptor 417 00:32:22.130 --> 00:32:29.930 called sphingosine 1 phosphate. The concentration of sphingosine 1 phosphate increases 418 00:32:30.430 --> 00:32:34.030 as you the lymphocytes go away from lymph nodes. So it is 419 00:32:34.030 --> 00:32:37.930 attracted in this way. If you can disrupt this sphingosine 1 phosphate 420 00:32:37.930 --> 00:32:42.630 receptor, the lymphocyte uh will not be able to understand uh like 421 00:32:42.630 --> 00:32:46.230 will not be able to go across from the lymph node and 422 00:32:46.230 --> 00:32:48.930 it stays within the lymph node and there will be no inflammation. 423 00:32:49.430 --> 00:32:53.730 So there is an uh molecule called ozanimod which is in currently 424 00:32:53.730 --> 00:32:58.930 in trials which can deregulate this the can modulate 425 00:32:58.930 --> 00:33:04.230 this receptor of sphingosine one phosphate. Phosphate thus 426 00:33:04.230 --> 00:33:09.430 prevent the efflux of lymphocytes from lymph node. So and 427 00:33:09.430 --> 00:33:15.330 so these are the various molecules. So these are used. So just 428 00:33:15.630 --> 00:33:19.230 initially as I told you uh if you are not able to 429 00:33:19.230 --> 00:33:23.930 manage with aminosalicylates, then you need to step up it and for 430 00:33:23.930 --> 00:33:27.630 maintenance these are the various molecules that can be used. So I 431 00:33:27.630 --> 00:33:31.330 don't want to discuss in detail which one to use. You can 432 00:33:31.330 --> 00:33:37.630 use anything of these things, but every molecule has its its 433 00:33:37.730 --> 00:33:41.830 own pros and cons and costs. So various factors comes into role 434 00:33:41.830 --> 00:33:45.930 when deciding which one to be used. Like the risk of infections, 435 00:33:46.130 --> 00:33:49.430 whether the patient, how affordable is the patient and what is the 436 00:33:49.430 --> 00:33:54.630 drugs if the patient received earlier, how rapid action you are expecting? 437 00:33:54.930 --> 00:33:57.230 For example, if it is severe colitis if you are want a 438 00:33:57.230 --> 00:34:02.330 rapid action infliximab works but adalimumab and vedolizumab doesn't work. So 439 00:34:02.330 --> 00:34:05.530 it all depends on various factors, but just I want to introduce 440 00:34:05.530 --> 00:34:11.930 to the various molecules here. And second one more important important 441 00:34:11.930 --> 00:34:15.130 thing is because it is an in autoimmune disease. You are going 442 00:34:15.130 --> 00:34:19.430 to treat the patient with immunosuppressants. So all these patients should undergo 443 00:34:19.430 --> 00:34:23.630 vaccination. Although they are adults they should be vaccinated. They should require 444 00:34:23.630 --> 00:34:28.330 hepatitis B vaccine, hepatitis A vaccine, pneumococcal vaccine and next will be 445 00:34:28.330 --> 00:34:33.930 influenza vaccine, varicella vaccine. So vaccinations are important. So 446 00:34:33.930 --> 00:34:38.130 if these while if the higher molecules don't work or the patient 447 00:34:38.130 --> 00:34:42.930 is not affordable, surgery is the one of the option. So in 448 00:34:42.930 --> 00:34:48.130 surgery the in ulcerative colitis if the patient like 449 00:34:48.130 --> 00:34:51.130 the two indication if the patient is not responding to treatment or 450 00:34:51.130 --> 00:34:53.930 if the patient has severe complications like perforation, they need to go 451 00:34:53.930 --> 00:34:57.330 total colectomy. The total colon is removed and then they will make 452 00:34:57.330 --> 00:35:00.530 a pouch. They even rectum is removed and they will they may 453 00:35:00.630 --> 00:35:04.230 will make a pouch with ileum and with this this pouch will 454 00:35:04.230 --> 00:35:09.230 be attached to the anal can. So next is one 455 00:35:09.330 --> 00:35:12.930 what is the uh like in the last this is my last 456 00:35:12.930 --> 00:35:16.430 topic. I will be dealing with an emergency in ulcerative colitis that 457 00:35:16.430 --> 00:35:21.730 is called acute severe there are ulcerative colitis. So 458 00:35:21.830 --> 00:35:25.030 why do we need to diagnose this acute severe ulcerative colitis? because 459 00:35:25.330 --> 00:35:28.230 uh if a patient has severe ulcerative colitis, how can you diagnose 460 00:35:28.230 --> 00:35:31.530 it? Based on true and love true love and weights criteria if 461 00:35:31.530 --> 00:35:35.030 this two frequency is more than six and he has systemic signs 462 00:35:35.030 --> 00:35:39.430 like tachycardia or fever and if has high inflammatory markers and the 463 00:35:39.430 --> 00:35:43.230 total overall score is more than six then it's called acute severe 464 00:35:43.230 --> 00:35:48.530 ulcerative colitis. If you don't diagnose this in time, then the patient 465 00:35:48.530 --> 00:35:54.630 is at high risk of complications of perforation and 466 00:35:54.830 --> 00:35:58.130 death. So you need to identify this. So what you need to 467 00:35:58.130 --> 00:36:01.530 do at the admission rule out infectious causes as I told you 468 00:36:01.730 --> 00:36:06.430 CMV, Clostridium difficile and send the basic blood workup CBC, LFT, KFT 469 00:36:06.430 --> 00:36:10.230 and inflammatory markers CRP and never do a colonoscopy because they are 470 00:36:10.230 --> 00:36:14.830 at high risk of perforation. Just do a sigmoidoscopy and second start 471 00:36:14.830 --> 00:36:19.830 the patient on IV steroids. Uh added therapy 472 00:36:19.830 --> 00:36:23.030 in Indian settings because we cannot be doubly sure to rule out 473 00:36:23.030 --> 00:36:28.530 infection. we often give empirically IV 474 00:36:28.530 --> 00:36:33.530 antibiotics of ciprofloxacin and metronidazole and we stop the oral aminosalicylates and 475 00:36:33.530 --> 00:36:38.330 steroid dose would be 100 mg hydrocortisone six hourly. And we should 476 00:36:38.330 --> 00:36:43.230 continue the oral nutrition unless there is complication of perforation. And most 477 00:36:43.230 --> 00:36:48.430 important if the these patients will complain of pain, never never give 478 00:36:49.230 --> 00:36:54.130 anti-motility drugs for these patients. They patient come to us saying diarrhea. 479 00:36:54.430 --> 00:36:59.630 So if you give anti-motility drugs like loperamide or uh opioids 480 00:36:59.630 --> 00:37:04.830 like tramadol for pain. The dilatation 481 00:37:04.830 --> 00:37:08.830 of the colon increases and they the risk of corporation perforation worsens 482 00:37:09.230 --> 00:37:14.330 and also pain never give NSAIDs. NSAIDs cause further ulcerations. So 483 00:37:14.330 --> 00:37:19.330 never give painkillers of NSAIDs or tramadol or other opioids. Never 484 00:37:19.330 --> 00:37:23.130 give anti-motility drugs. Even even if this is the message you can 485 00:37:23.130 --> 00:37:26.830 take home this is very important. Please identify a case of acute 486 00:37:26.830 --> 00:37:31.630 or severe ulcerative colitis and don't give these drugs in those cases. 487 00:37:34.130 --> 00:37:39.630 And don't give any enemas. And next 488 00:37:39.930 --> 00:37:42.830 uh what to do? How to say that patient is responding to 489 00:37:42.830 --> 00:37:46.930 treatment? At day three we follow Oxford criteria where the stool frequency 490 00:37:47.030 --> 00:37:50.030 comes to less than three and CRP less than 45 then he's 491 00:37:50.030 --> 00:37:54.230 improving. Change from IV to oral steroids and discharge the patient. If 492 00:37:54.230 --> 00:37:59.830 their incomplete responders and non-responders, non-responders means more than eight stool frequency 493 00:37:59.930 --> 00:38:03.230 or high CRP of more than 45, then we need to go 494 00:38:03.230 --> 00:38:07.430 for rescue therapy. What are the rescue therapy we have like after 495 00:38:07.630 --> 00:38:11.530 day five of IV steroids still he is not responding. One is 496 00:38:11.530 --> 00:38:16.730 surgery. Second is biologicals that 497 00:38:16.730 --> 00:38:21.430 is infliximab or third is cyclosporine and fourth one now new entity 498 00:38:21.430 --> 00:38:26.830 is tofacitinib JAK 2 inhibitors. So these are the things and so 499 00:38:27.030 --> 00:38:31.630 uh based this is a severe ulcerative colitis and ulcerative colitis patients 500 00:38:31.630 --> 00:38:36.830 are at risk of developing colorectal cancer. So even we in USA 501 00:38:37.230 --> 00:38:41.830 screening colonoscopy starts at 45 to 50 years of age. But these 502 00:38:41.830 --> 00:38:46.830 ulcerative colitis once you diagnose, they need to undergo screening colonoscopy 503 00:38:47.230 --> 00:38:52.230 at interval based on the risk under 504 00:38:52.230 --> 00:38:54.930 there. Usually if they have no other risk factors, a case of 505 00:38:54.930 --> 00:38:59.130 ulcerative colitis should undergo colonoscopy every five years. Okay. And this is 506 00:38:59.130 --> 00:39:02.330 the end of the topic. Thank you all. In uh this is 507 00:39:02.330 --> 00:39:05.930 a small message. Always have a mentor with you to guide your 508 00:39:06.130 --> 00:39:11.330 to guide you. They motivate you, they guide you, they 509 00:39:11.330 --> 00:39:15.230 give uh they make you understand the subject, they train you, support 510 00:39:15.230 --> 00:39:18.930 you, coach you. And one of my mentor is Vineet Ahuja. He 511 00:39:18.930 --> 00:39:24.930 is a professor in All India Institute of Medical Sciences. Whatever for 512 00:39:24.930 --> 00:39:29.830 uh my gastroenterology especially IBD I bow to him and my alma 513 00:39:29.830 --> 00:39:32.830 mater All India Institute of Medical Sciences. Thank you all for your 514 00:39:32.830 --> 00:39:37.830 patient listening. Thank you so much 515 00:39:37.830 --> 00:39:40.130 sir for taking your time out for us and giving such a 516 00:39:40.130 --> 00:39:45.130 wonderful session today. It was really a quite informative one sir. Uh 517 00:39:45.630 --> 00:39:48.430 sir before we go to the questions, can you tell us any 518 00:39:48.430 --> 00:39:54.930 three take home messages to all our attendees for today's session? Yeah. 519 00:39:55.430 --> 00:40:01.230 First one, should you please when whenever 520 00:40:01.230 --> 00:40:05.830 patient comes with bloody diarrhea. So just one first point is is 521 00:40:05.830 --> 00:40:11.230 it infectious or non-infectious? In fact so acute any history of fever 522 00:40:11.330 --> 00:40:16.530 mostly infectious, evaluate for infectious diseases. So let the people 523 00:40:16.530 --> 00:40:21.030 never if you the patient is not responding to antibiotics, just don't 524 00:40:21.030 --> 00:40:25.630 escalate your antibiotics. Understand that other causes of large bowel bloody diarrhea 525 00:40:25.630 --> 00:40:29.330 is there like ulcerative colitis is there. That is point number one. 526 00:40:29.730 --> 00:40:35.230 Point number two, please make understand that 527 00:40:35.230 --> 00:40:39.230 like speak to the patients. It's a lifelong disease like diabetes, hypertension. 528 00:40:39.430 --> 00:40:42.030 You need you need the patient need to travel with you. So 529 00:40:42.030 --> 00:40:45.930 make them understand the importance of continuing your drugs and assure them 530 00:40:45.930 --> 00:40:50.630 that with proper therapy we can completely control the disease and make 531 00:40:50.630 --> 00:40:54.330 it under control and they can lead a normal life entirely. And 532 00:40:54.330 --> 00:40:59.130 third always try to diagnose acute severe ulcerative colitis based on the 533 00:40:59.130 --> 00:41:04.230 true love weights criteria and please do refer to any expert center 534 00:41:04.430 --> 00:41:11.430 for the management to avoid complications. And in such cases never 535 00:41:11.430 --> 00:41:16.230 give anti-motility like drugs like loperamide. So please do understand that acute 536 00:41:16.230 --> 00:41:21.330 infectious even infectious diarrhea especially with infective never give anti-motility drugs like 537 00:41:21.330 --> 00:41:26.230 loperamide without antibiotic cover. For example in ulcerative colitis if because it 538 00:41:26.230 --> 00:41:31.730 is non-infectious you cannot give it in any circumstances. Uh 539 00:41:31.930 --> 00:41:36.430 thank you sir for answering that. We have one question. Uh 29 540 00:41:36.430 --> 00:41:41.430 years old male feeling a stomach ache after drinking milk like can 541 00:41:41.430 --> 00:41:48.530 you tell us what your diagnosis point of view sir? So 542 00:41:50.830 --> 00:41:55.930 although it is unrelated to topic, so this one uh here 543 00:41:56.030 --> 00:42:01.030 the important thing is the stomach ache after 544 00:42:01.030 --> 00:42:05.830 only milk intake specifically. There are two possibilities. one is all cause 545 00:42:05.830 --> 00:42:09.630 like any peptic ulcer disease or gastritis has to be taken care. 546 00:42:10.030 --> 00:42:16.230 Sometimes milk intolerance can present as such thing. Thank 547 00:42:16.230 --> 00:42:19.530 you so much sir for answering. We'll go to the next question 548 00:42:19.530 --> 00:42:24.630 sir. What are the what are the long-term complications and 549 00:42:24.630 --> 00:42:29.930 potential side effects of ulcerative colitis? So 550 00:42:29.930 --> 00:42:34.830 long-term complications if the patient responds to treatment, there will be no 551 00:42:34.830 --> 00:42:39.830 long-term complication. The complications will be related to medical therapy. Uh main 552 00:42:39.830 --> 00:42:43.630 thing is as I told you colonic cancer is a risk factor. 553 00:42:43.630 --> 00:42:48.830 So you need to screen them at regular intervals to detect 554 00:42:48.830 --> 00:42:54.330 any early cancer and treat that. That that 555 00:42:54.330 --> 00:42:59.030 is point number one. And potential complications if acute severe ulcerative colitis 556 00:42:59.130 --> 00:43:06.730 would be perforation. Thank 557 00:43:06.730 --> 00:43:09.730 you for answering that sir. We have one more question. Can you 558 00:43:09.730 --> 00:43:13.530 explain the role of a diet and nutrition how it impact an 559 00:43:13.530 --> 00:43:18.930 ulcerative colitis uh this So 560 00:43:18.930 --> 00:43:22.830 diet coming to diet there is no dietary restriction for ulcerative colitis 561 00:43:22.830 --> 00:43:27.230 at all. In Crohn's disease the data showed there can be exclude 562 00:43:39.830 --> 00:43:41.830 who enteral nutrition can help in a Crohn's disease. But for ulcerative 563 00:43:33.530 --> 00:43:37.830 colitis maintain a healthy diet. That's it. So healthy diet itself we 564 00:43:37.830 --> 00:43:39.830 know that uh avoid processed food, stored food, prefer fresh thing. 565 00:43:44.130 --> 00:43:47.130 There is no need to avoid any non-vegetarian diet. You can continue 566 00:43:47.130 --> 00:43:51.830 that. Main is fresh diet and non-processed like not highly refined food. 567 00:43:52.530 --> 00:43:57.830 You can also continue milk. And but in Crohn's there are other 568 00:43:58.730 --> 00:44:04.130 problems like uh Crohn's they if 569 00:44:04.130 --> 00:44:08.130 the patient has severe disease we can stop the dietary they regular 570 00:44:08.130 --> 00:44:11.230 diet and continue the patient on enteral nutrition. There is a special 571 00:44:11.230 --> 00:44:15.330 form of formula feeds. And coming to duration of treatment for ulcerative 572 00:44:15.330 --> 00:44:19.630 colitis, it is a lifelong treatment. We need to give the once 573 00:44:19.630 --> 00:44:24.330 induction is achieved, we need to continue the treatment for lifelong maintenance. 574 00:44:25.130 --> 00:44:29.330 And milk intolerance is curable less likely at the after the age 575 00:44:29.330 --> 00:44:35.030 of five years the enzyme which uh so 576 00:44:35.030 --> 00:44:40.330 after the the age of five years the enzyme lactase 577 00:44:40.330 --> 00:44:44.730 which is responsible for digesting lactose is disappears in 95 more than 578 00:44:44.730 --> 00:44:48.430 95% of the adults. So some may not develop if a person 579 00:44:48.430 --> 00:44:52.930 develops milk intolerance usually it will be life. But you can continue 580 00:44:52.930 --> 00:44:57.530 take milk like milk products that doesn't contain lactose like paneer or 581 00:44:57.630 --> 00:44:57.930 curd.