Left-sided colitis

Left-sided colitis

  • If not already performed, plan index colonoscopy to classify disease unless intercurrent moderate / severe disease

  • Define schedule for surveillance

  • Consider 5-ASA as chemoprevention against cancer

  • Ensure vaccines updated

  • Provide patient education

  • Provide contact details in case of disease flare

Joint treatment plan

ECCO statement 2B (UC 2017)

Disease severity influences treatment modality and route of administration [EL1]. Clinical indices of disease severity have not been adequately validated, although clinical, laboratory, imaging, and endoscopic parameters, including histopathology, impact on patients’ management [EL 2]. Remission is defined as stool frequency ≤ 3/day, no rectal bleeding, and normal mucosa at endoscopy [EL5]. Absence of a histological acute inflammatory infiltrate predicts quiescent course of disease [EL3]

Further information

  • Assess activity using Truelove and Witts or the Mayo scale

  • Upgrade to more active category if symptoms refractory to appropriate treatment

Assess disease activity

Quiescent

Mild

Moderate

Severe

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations ; and response and side-effects of medication

  • Oral maintenance therapy should be >/= 2 g; 1 g daily topical therapy may be an alternative.

  • Determine follow-up schedule (e.g. on demand or in 6 months; sooner if recent moderate/severe disease)

Mesalazine

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

ECCO statement 11D (UC 2017)

Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Oral beclomethasone dipropionate 5 mg/day has similar efficacy and safety profile as oral prednisone in patients with mild to moderately active ulcerative colitis [EL2]. Budesonide MMX 9 mg/day can be considered in patients with mild to moderate disease who are intolerant or refractory to aminosalicylates [EL2]. Severe left-sided colitis is an indication for hospital admission [EL1]

Further information

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations; and response and side-effects of medication

  • Generally, treatment escalated if relapse occurs, or continues (e.g. > 1 month) on treatment, as follows: mesalazine PO or enema -> mesalazine PO & enema -> add oral steroids

  • Plan maintenance therapy

  • Determine follow-up schedule (e.g. 3 months)

Topical and/or
oral mesalazine

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

ECCO statement 11D (UC 2017)

Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Oral beclomethasone dipropionate 5 mg/day has similar efficacy and safety profile as oral prednisone in patients with mild to moderately active ulcerative colitis [EL2]. Budesonide MMX 9 mg/day can be considered in patients with mild to moderate disease who are intolerant or refractory to aminosalicylates [EL2]. Severe left-sided colitis is an indication for hospital admission [EL1]

Further information

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations; and response and side-effects of medication

  • Generally, treatment escalated if relapse occurs, or continues (e.g. > 1 month) on treatment, as follows: mesalazine PO or enema -> mesalazine PO & enema -> add oral steroids

  • Plan maintenance therapy

  • Determine follow-up schedule (e.g. 6 weeks)

Topical and oral mesalazine

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

ECCO statement 11D (UC 2017)

Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Oral beclomethasone dipropionate 5 mg/day has similar efficacy and safety profile as oral prednisone in patients with mild to moderately active ulcerative colitis [EL2]. Budesonide MMX 9 mg/day can be considered in patients with mild to moderate disease who are intolerant or refractory to aminosalicylates [EL2]. Severe left-sided colitis is an indication for hospital admission [EL1]

Further information

  • Provide steroids and mesalazine both orally and topically. Some patients can delay starting oral steroids for 10-14 days if enemas are retained

  • Response should occur within 2 weeks of starting oral steroids

  • Plan maintenance therapy

  • Determine follow-up schedule (e.g. 1-2 weeks)

Mesalazine & steroids. Consider need for hospital admission

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

Further information

  • Confirm relapse with flexible sigmoidoscopy (some patients can be treated empirically with dose escalation, depends on disease duration and activity, previous disease course including response and side-effects of medication), including request to exclude CMV

  • Check stool culture and C. difficile assay (and parasites if travel history)

Reassess disease

Assess response

Assess response

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

ECCO statement 11D (UC 2017)

Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Oral beclomethasone dipropionate 5 mg/day has similar efficacy and safety profile as oral prednisone in patients with mild to moderately active ulcerative colitis [EL2]. Budesonide MMX 9 mg/day can be considered in patients with mild to moderate disease who are intolerant or refractory to aminosalicylates [EL2]. Severe left-sided colitis is an indication for hospital admission [EL1]

Further information

  • Treat based on disease activity and extent

  • Exclude C. difficile & CMV infection in those hospitalised or who have received antibiotics recently

  • Add thiopurine if relapse within 3 months of steroid-induced remission

Treatment based on activity / extent

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

ECCO statement 11D (UC 2017)

Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Oral beclomethasone dipropionate 5 mg/day has similar efficacy and safety profile as oral prednisone in patients with mild to moderately active ulcerative colitis [EL2]. Budesonide MMX 9 mg/day can be considered in patients with mild to moderate disease who are intolerant or refractory to aminosalicylates [EL2]. Severe left-sided colitis is an indication for hospital admission [EL1]

Further information

  • Reassess disease activity ± extent with flexible sigmoidoscopy (some patients can be treated empirically with dose escalation, depends on disease duration and activity, previous disease course including response and side-effects of medication) . Screen colonic biopsies for CMV infection in treatment refractory disease

  • Exclude C. difficile infection if treatment refractory or following recent antibiotic use

  • Generally, treatment escalated if relapse occurs, or continues (e.g. > 1 month) on treatment, as follows: mesalazine PO or enema -> mesalazine PO & enema -> add oral steroids. Some but not all studies suggest greater benefit from higher mesalazine doses (4.8 vs. 2.4 g/d)

  • Provide steroids and mesalazine both orally and topically. Some patients can delay starting oral steroids for 10-14 days if enemas are retained.
Add topical and/or oral steroids

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

Further information

  • Flexible sigmoidoscopy and biopsy to assess response and exclude other diagnoses. Screen colonic biopsies for CMV infection in treatment refractory disease

  • Exclude C. difficile infection in treatment refractory or following recent antibiotic use

Sigmoidoscopy

Assess response

Continue treatment & reassess response

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

ECCO statement 11D (UC 2017)

Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Oral beclomethasone dipropionate 5 mg/day has similar efficacy and safety profile as oral prednisone in patients with mild to moderately active ulcerative colitis [EL2]. Budesonide MMX 9 mg/day can be considered in patients with mild to moderate disease who are intolerant or refractory to aminosalicylates [EL2]. Severe left-sided colitis is an indication for hospital admission [EL1]

ECCO statement 12D (UC 2017)

Options for a stepwise escalation of maintenance therapy include dose escalation of oral/rectal aminosalicylates [EL1], the addition of thiopurines [EL2], and anti-TNF therapy or vedolizumab [EL1]

Further information

  • Treatment escalation usually requires admission to hospital for IV steroids (depends on disease duration and activity; previous disease course including extra-intestinal manifestations; and response and side-effects of medication)

  • Admission mandated if severe colitis based on the Truelove and Witts scale

  • Alternative (out-patient) treatments, particularly in those known to be steroid refractory, include anti-TNF, ciclosporin, tacrolimus

Escalate treatment

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

Further information

  • Reassess disease activity and extent if continued relapse despite treatment escalation, and treat accordingly

  • Consider flexible sigmoidoscopy and biopsy to assess response and exclude other diagnoses including CMV

Reassess activity and extent

Consider need for admission to hospital

Maintenance of remission

Maintenance of remission

  • Treatment depends on disease duration and activity; previous disease course including extra-intestinal manifestations ; and response and side-effects of medication

  • Oral maintenance therapy should be >/= 2 g; 1 g daily topical therapy may be an alternative.

  • Determine follow-up schedule (e.g. on demand or in 6 months; sooner if recent moderate/severe disease)

Mesalazine

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

Further information

  • Confirm relapse with flexible sigmoidoscopy (some patients can be treated empirically with dose escalation, depends on disease duration and activity, previous disease course including response and side-effects of medication), including request to exclude CMV

  • Check stool culture and C. difficile assay (and parasites if travel history)

Reassess disease

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

ECCO statement 11C (UC 2017)

Mild to moderately active left-sided ulcerative colitis should initially be treated with an aminosalicylate enema ≥ 1 g/day [EL1] combined with oral mesalamine ≥ 2.4 g/day [EL1], which is more effective than oral or topical aminosalicylates, or topical steroids alone [EL1]. Topical mesalamine is more effective than topical steroids [EL1]. Once-daily dosing with mesalamine is as effective as divided doses [EL1]

ECCO statement 11D (UC 2017)

Systemic corticosteroids are appropriate in patients with moderate to severe activity and in those with mild activity who do not respond to mesalamine [EL1]. Oral beclomethasone dipropionate 5 mg/day has similar efficacy and safety profile as oral prednisone in patients with mild to moderately active ulcerative colitis [EL2]. Budesonide MMX 9 mg/day can be considered in patients with mild to moderate disease who are intolerant or refractory to aminosalicylates [EL2]. Severe left-sided colitis is an indication for hospital admission [EL1]

Further information

  • Treat based on disease activity and extent

  • Exclude C. difficile & CMV infection in those hospitalised or who have received antibiotics recently

  • Add thiopurine if relapse within 3 months of steroid-induced remission

Treatment based on activity / extent

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