Definitions for level of evidence (1-3) and strength of recommendation (A-D) are given at the end of the "Major Recommendations" field.
Recommendations for Diagnosis and Assessment
In a patient presenting with persistent bloody diarrhea, rectal urgency, or tenesmus, stool examinations and sigmoidoscopy or colonoscopy and biopsy should be performed to confirm the presence of colitis and to exclude the presence of infectious and noninfectious etiologies. Characteristic endoscopic and histologic findings with negative evaluation for infectious causes will suggest the diagnosis of ulcerative colitis (UC).
Approach to Management
Goals of treatment are induction and maintenance of remission of symptoms to provide an improved quality of life, reduction in need for long-term corticosteroids, and minimization of cancer risk.
Recommendations for Management of Mild-Moderate Distal Colitis
Patients with mild to moderate distal colitis may be treated with oral aminosalicylates, topical mesalamine, or topical steroids (Evidence A). Topical mesalamine agents are superior to topical steroids or oral aminosalicylates (Evidence A). The combination of oral and topical aminosalicylates is more effective than either alone (Evidence A). In patients refractory to oral aminosalicylates or topical corticosteroids, mesalamine enemas or suppositories may still be effective (Evidence A). The unusual patient who is refractory to all of the above agents in maximal doses, or who is systemically ill, may require treatment with oral prednisone in doses up to 40–60 mg per day, or infliximab with an induction regimen of 5 mg/kg at weeks 0, 2, and 6, although the latter two agents have not been studied specifically in patients with distal disease (Evidence C).
Recommendations for Maintenance of Remission in Distal Disease
Mesalamine suppositories are effective in the maintenance of remission in patients with proctitis, whereas mesalamine enemas are effective in patients with distal colitis when dosed even as infrequently as every third night (Evidence A). Sulfasalazine, mesalamine compounds, and balsalazide are also effective in maintaining remission; the combination of oral and topical mesalamine is more effective than either one alone (Evidence A). Topical corticosteroids including budesonide, however, have not proven effective for maintaining remission in distal colitis (Evidence A). When all of these measures fail to maintain remission in distal disease, thiopurines (6-mercaptopurine [6-MP] or azathioprine) and infliximab (Evidence A), but not corticosteroids, may prove effective (Evidence B).
Recommendations for Mild-Moderate Extensive Colitis: Active Disease
Patients with mild to moderate extensive colitis should begin therapy with oral sulfasalazine in daily doses titrated up to 4–6 g per day, or an alternate aminosalicylate in doses up to 4.8 g per day of the active 5-aminosalicylate acid (5-ASA) moiety (Evidence A). Oral steroids are generally reserved for patients who are refractory to oral aminosalicylates in combination with topical therapy, or for patients whose symptoms are so troubling as to demand rapid improvement (Evidence B). 6-MP and azathioprine are effective for patients who do not respond to oral steroids, and continue to have moderate disease, and are not so acutely ill as to require intravenous therapy (Evidence A). Infliximab is an effective treatment for patients who are steroid refractory or steroid dependent despite adequate doses of a thiopurine, or who are intolerant of these medications. The infliximab induction dose is 5 mg/kg intravenously at weeks 0, 2, and 6 weeks (Evidence A). Infliximab is contraindicated in patients with active infection, untreated latent tuberculosis (TB), preexisting demyelinating disorder or optic neuritis, moderate to severe congestive heart failure, or current or recent malignancies.
Recommendations for Mild-Moderate Extensive Colitis: Maintenance of Remission
Once the acute attack is controlled, a maintenance regimen is usually required, especially in patients with extensive or relapsing disease. Sulfasalazine, olsalazine, mesalamine, and balsalazide are all effective in reducing relapses (Evidence A). Patients should not be treated chronically with steroids. Azathioprine or 6-MP may be useful as steroid-sparing agents for steroid-dependent patients and for maintenance of remission not adequately sustained by aminosalicylates, and occasionally for patients who are steroid dependent but not acutely ill (Evidence A). Infliximab is effective in maintaining improvement and remission in the patients responding to the infliximab induction regimen (Evidence A).
Recommendations for Management of Severe Colitis
The patient with severe colitis refractory to maximal oral treatment with prednisone, oral aminosalicylate drugs, and topical medications may be treated with infliximab 5 mg/kg if urgent hospitalization is not necessary (Evidence A). The patient who presents with toxicity should be admitted to hospital for a course of intravenous steroids (Evidence C). Failure to show significant improvement within 3–5 days is an indication for either colectomy (Evidence B) or treatment with intravenous cyclosporine (CSA; Evidence A) in the patient with severe colitis. Long-term remission in these patients is significantly enhanced with the addition of maintenance 6-MP (Evidence B). Infliximab may also be effective in avoiding colectomy in patients failing intravenous steroids but its long-term efficacy is unknown in this setting (Evidence A).
Recommendations for Surgery
Absolute indications for surgery are exsanguinating hemorrhage, perforation, and documented or strongly suspected carcinoma (Evidence C). Other indications for surgery are severe colitis with or without toxic megacolon unresponsive to conventional maximal medical therapy, and less severe but medically intractable symptoms or intolerable medication side effects (Evidence C).
Recommendations for Management of Pouchitis
Patients who develop typical symptoms and signs of pouchitis after the ileal pouch-anal anastomosis (IPAA) should be treated with a short course of antibiotics (Evidence A). Controlled trial studies show efficacy for metronidazole in a dose of 400 mg three times daily, or 20 mg/kg daily, or ciprofloxacin 500 mg twice daily (Evidence A). Other etiologies mimicking pouchitis include irritable pouch syndrome, cuffitis, Crohn's disease of the pouch, and postoperative complications such as anastomotic leak or stricture. Inadequate evidence exists to recommend routine surveillance of the pouch for dysplasia or adenocarcinoma (Evidence C).
Recommendations for Cancer Surveillance
After 8–10 years of colitis, annual or biannual surveillance colonoscopy with multiple biopsies at regular intervals should be performed (Evidence B). The finding of high-grade dysplasia (HGD) in flat mucosa, confirmed by expert pathologists' review, is an indication for colectomy, whereas the finding of low-grade dysplasia (LGD) in flat mucosa may also be an indication for colectomy to prevent progression to a higher grade of neoplasia (Evidence B).
Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), Grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and Grade D recommendations are based on level 5 evidence, meaning expert opinion.