Parambir Dulai, MD, on Getting the Hospitalized Patient Well and Home Safely

Acute severe ulcerative colitis (UC), acute penetrating Crohn disease (CD), and stricturing complications of CD are among the complications of inflammatory bowel disease (IBD) that require hospitalization, Parambir Dulai, MD, explained to the Advances in Inflammatory Bowel Diseases (AIBD) virtual regional meeting on March 5.

Dr Dulai is a gastroenterologist at Northwestern Medicine Digestive Health Center in Chicago, Illinois.

The goal with all patients is to help them get well and go home safely, he said. Each of these conditions has its own particular challenges and options for treatment.

A patient with acute severe UC will have a Mayo score of 3, with 6 to 8 bowel movements daily and bloody stool. “It’s really important that the patient be hospitalized for IV hydration, rapid evaluation of comorbid or concomitant conditions, and IV steroids,” Dr Dulai said.

Lower endoscopy is the mainstay for diagnostic evaluation of acute severe UC, he stated, “not only because it assesses and quantifies disease activity but also because it’s important to rule out CMV [cytomegalovirus]. It’s also helpful for prognosis. Deep ulcerations at baseline are associated with nonresponse to steroids, so in these patients you may consider early escalation to second-line medications.”

Intravenous corticosteroids are the central pillar of early treatment for the hospitalized patient with acute severe UC, Dr Dulai said. Professional guidelines call for 40 to 60 mg of solumedrol once daily or 100 mg hydrocortisone 3 to 4 times day to get inflammation under control quickly.

“It’s imperative that providers get stool studies to rule out C diff [Cloistridioides difficile] which can be present in up to 30% of patients, and other infectious triggers,” Dr Dulai stated. If CMV is detected, the recommended treatment is IV ganciclovir; for C diff, high-dose vancomycin is the first-line therapy.

Blood work should be done daily: complete blood count, basic metabolic panel, C-reactive protein (CRP), and erythrocyte sedimentation rate should be checked daily, he said, adding that “a CRP of more than 45 mg/L is associated with nonresponse to steroids, so you should keep a close eye on that.”

Assess patients for signs of toxicity requiring surgical evaluation, Dr Dulai stated, and get surgical colleagues involved early. “And I cannot stress this enough—you need VTE prophylaxis with heparin-based products, given the high risk of VTE seen in this population.”

Patients who do not respond to IV corticosteroids may be escalated to infliximab or cyclosporine. Consider repeat dosing with infliximab in-hospital for partial responders, Dr Dulai recommended. It’s also unclear if accelerated dosing of infliximab confers any benefit in post-discharge outcomes. “Most importantly, repeat dosing should not delay surgical evaluation, because the longer you wait for surgery, the poorer the surgical outcomes will be.”

Tofacitinib rescue therapy is an emerging consideration for patients with acute severe UC who have been exposed to biologics and therefore are not good candidates for infliximab, he said. A retrospective case control study of acute severe UC flares showed a 70% reduction in 3-month colectomy rates among patients treated with tofacitinib 10 mg 3 times daily. Dr Dulai noted that this dose is off-label, and the risks are unclear; on discharge, the dosing should revert to the approved dose of 10 mg twice daily.

Hyperbaric oxygen therapy is also showing promise among patients with acute severe UC who had not responded to outpatient corticosteroids or biologics. At days 5 and 10, patients receiving hyperbaric oxygen therapy had significantly higher remission rates than the placebo cohort, while the rate of progression to in-hospital second-line therapy or colectomy was substantially lower.       

Patients with acute severe UC may be discharged when they achieve resolution of bleeding and improvement in stool frequency, Dr Dulai stated. For patients who have responded to corticosteroid therapy, he suggested, “Consider monitoring on oral prednisone 24 hours prior to discharge; 40-60mg prednisone is the appropriate discharge dosing.”

Among patients who present with high fever, a palpable mass, or who are on chronic corticosteroids, acute internal penetrating CD with intra-abdominal mass should be suspected. “Imaging is paramount in these patients,” Dr Dulai stressed. Diagnosing an intra-abdominal abscess requires imaging with computed tomography (CT) or magnetic resonance imaging (MRI), which demonstrate comparable sensitivity.

“Colonoscopy is also important to help quantify extent and severity of disease and to guide treatment, because treatment of inflammation alongside treatment of the abscesses or fistulas is important to help treat the Crohn’s and prevent recurrence, he said. You must treat both of them.”

Dr Dulai presented a flow diagram to guide decision making for patients with acute internal penetrating CD. If an abscess is detected but is >3 cm, is not a recurrence, and the patient is not on corticosteroids, then the treatment can begin with antibiotics. The patient should be assessed for response and reimaged in 3 to 5 days for resolution.

However, if the patient has a larger abscess, a recurrent abscess, or has been on corticosteroids, then, Dr Dulai stated, “you want to focus on drainage and control, followed by antibiotics.” Percutaneous drainage is preferred, followed by antibiotics; if percutaneous drainage is not successful, then the patient should receive total parenteral nutrition and continued antibiotics prior to surgical drainage. Follow-up imaging should be conducted in the outpatient setting.

“It’s important to know that stricturing complications of Crohn’s disease have a highly variable presentation,” Dr Dulai said. “They can present as small bowel obstruction, partial obstruction, postprandial pain, or inability to tolerate solid food. Sometimes these patients have been on a liquid diet for weeks before they present to you.”

There are 4 key components to supportive therapy for stricturing disease: bowel decompression, hydration, electrolytes, and nutritional support.

“All patients require cross-sectional imaging to map the extent and number of strictures because this will guide treatment selection.” However, this imaging alone is not reliable in distinguishing fibrosis from inflammation, so the clinician will also need to use markers such as CRP and, if safe, colonoscopy, to identify if corticosteroids will be beneficial in these patients.

Surgery likely will be needed if prestenotic dilation and small bowel strictures greater than 3 cm are found. “When feasible, colonoscopy is an option with balloon dilation, if the stricture is accessible by lower endoscopy, a single ulcer less than 5cm in size, nonangulated, with no overlying ulcers on the stricture.”

Patients with objective evidence of inflammation can be escalated to medical therapy via corticosteroids or optimization of therapy. If the patient fails to respond to medical therapy or inflammation is absent, assess whether the patient is a candidate for endoscopic balloon dilation or surgery.

“One important consideration for any hospitalized patient is care coordination and the impact this has on outcomes,” Dr Dulai emphasized.

Certain factors seen in the emergency department (ED) that are predictive of a complicated course include tachycardia at triage; hypotension in ED; hypoalbuminemia at presentation; and Clostridioides difficile (C diff) infection. These patients are 2 to 3 times more likely to have complicated disease and to need multidisciplinary care, Dr Dulai stated.

A single-center case-control study of a dedicated inpatient IBD center demonstrated that this approach to care for patients with IBD improves outcomes, he said. It showed improved testing rates for C diff, earlier use of VTE prophylaxis, reduced use of narcotics, and lower rates of readmission and repeat ED visits after discharge.

“I can’t stress this enough,” Dr Dulai stated. “Multidisciplinary care is extremely important for these high-risk, sick patients in the hospital to effectively control and discharge them safely to home.”

—Rebecca Mashaw

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Reference:
Dulai, P. Getting the hospitalized patient well, and home safely. Presented at: Advances in Inflammatory Bowel Diseases regional meeting. March 5, 2022. Virtual