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In acute colitis, the diagnosis is readily established by sigmoidoscopy The mucosal appearance is characterized by edema, friability, mucopus, and erosions Colonoscopy should not be performed in patients with severe disease because of the risk of perforation After patients have demonstrated improvement on therapy, colonoscopy is sometimes performed to determine the extent of disease



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Patients with disease confined to the rectum or rectosigmoid region generally have mild but distressing symptoms Treatment of acute disease is best approached with topical agents Topical mesalamine is the drug of choice and is superior to topical corticosteroids Mesalamine is administered as a suppository, 1000 mg once daily at bedtime for proctitis, and as an enema, 4 g at bedtime for proctosig-

Plain abdominal radiographs are obtained in patients with severe colitis to look for significant colonic dilation Bar-





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Distal colitis Proctitis Mesalamine suppositories, 1000 mg per rectum once daily, or Hydrocortisone foam, 90 mg per rectum daily, or Hydrocortisone suppositories, 100 mg per rectum daily Proctosigmoiditis Mesalamine enema, 4 g per rectum daily, or Hydrocortisone enema, 100 mg per rectum daily Extensive colitis Mild to moderate Sulfasalazine, 1 15 g orally twice daily, or Mesalamine tablets (delayed-release), 20 48 g daily, or Balsalazide, 225 g three times a day If no response after 2 4 weeks, add mesalamine enema 4 g daily or prednisone, 40 60 mg daily (taper by 5 mg/wk) Severe Methylprednisolone, 48 60 mg IV daily

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have greater efficacy but are poorly tolerated Folic acid, 1 mg/d, should be administered to all patients taking sulfasalazine 2 Corticosteroids Patients with mild to moderate disease who do not improve after 2 3 weeks of 5-ASA therapy should have the addition of corticosteroid therapy The addition of topical therapy with 5-ASA enemas (4 g once daily) or hydrocortisone foam or enemas (80 100 mg once or twice daily) may be tried first Patients who do not improve after 2 more weeks require systemic corticosteroid therapy Prednisone and methylprednisolone are most commonly used Depending on the severity of illness, the initial oral dose of prednisone is 40 60 mg daily Rapid improvement is observed in most cases within 2 weeks Thereafter tapering of prednisone should proceed by 5 10 mg/wk After tapering to 15 mg/d, slower tapering is sometimes required Complete tapering without symptomatic flare-ups is possible in the majority of patients 3 Immunomodulating agents A subset of patients either does not respond to aminosalicylates or corticosteroids or has symptomatic flares during attempts at corticosteroid tapering Although surgical resection is traditionally recommended for patients with refractory disease, some patients may wish to avoid surgery and others have moderately severe disease for which surgery might not otherwise be warranted Immunomodulating agents are increasingly used for the treatment of ulcerative colitis; however, the risks of these drugs from chronic immunosuppression must be weighed against the certainty of cure with surgical resection Limited trials suggest mercaptopurine or azathioprine is of benefit in 60% of patients, allowing tapering of corticosteroids and maintenance of remission There is less evidence that methotrexate is effective Infliximab is approved in the United States for the treatment of patients with moderate to severe ulcerative colitis who have had an inadequate response to conventional therapies (oral corticosteroids, mercaptopurine or azathioprine, and mesalamine) Following a three-dose induction regimen of 5 mg/kg administered at 0, 2, and 6 weeks, clinical response occurs in 65% and clinical remission in 35%.

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