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  • Initial Workup for Acute Ulcerative Colitis (ED Ulcerative Colitis)

    ED

    Acute Ulcerative Colitis

    IBD Acute Ulcerative Colitis Medical Management v.2.0

    To Inpatient Treatment

    Executive Summary Explanation of Evidence Ratings

    Test Your Knowledge Summary of Version Changes

    Admit Criteria PUCAI >65 OR

    6 or more bloody bowel movements/day

    AND one of the following: tachycardia,

    fever, anemia, elevated ESR OR

    Dehydration, unable to take oral

    medications or oral resuscitation

    Off

    Pathway

    Discharge

    Instructions ED Ulcerative

    Colitis handout

    Follow-up plan as

    discussed with GI

    ED Inclusion Criteria Known ulcerative colitis

    Exclusion Criteria Toxic megacolon

    Known active infection including

    CMV, C difficile, or TB

    Crohns disease

    Gastrointestinal (GI) perforation

    First-line Treatment for Acute Severe Ulcerative Colitis Discuss treatment plan with GI

    First-line treatment methylPREDNISolone 1.5mg/kg IV max 60mg daily 0800 (may give first dose in ED, if first dose given after

    midnight give second dose the following day at 0800)

    Patients established on steroids: continue and add stress dose

    Antibiotics if at risk for C. difficile

    For patients who have received outpatient treatment (6-mercaptopurine, azathioprine, infliximab, course of oral steroids) discuss

    alternate next steps with GI

    Admit

    Discharge

    No, consider admit criteria

    Clinical assessment, labs, stool

    Nurse to complete PUCAI score tool

    Consider abdominal X-ray and surgical consult for symptoms

    such as severe pain, abdominal distention, guarding or

    rigidity, fever (>38.5C), shock

    Assess for dehydration

    Assess pain

    Withhold 5-ASA, 6-mercaptopurine, and azathioprine

    Avoid routine use of opiates or NSAIDs

    NPO except for medications

    Active CMV, C diffcile or Tb?

    Consider exclusion criteria

    Yes

    Assess pain

    Avoid routine use of opiates or NSAIDs

    Clinical assessment, labs, stool

    Nurse to complete PUCAI score tool

    Pain management

    First-line Treatment for Acute Severe Ulcerative Colitis (ED Ulcerative Colitis)

    Antibiotics if at risk for C. difficile

    Toxic Megacolon,

    For questions concerning this pathway,

    contact: IBDPathway@seattlechildrens.org 2015, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

    Last Updated: June 2015

    Next Expected Review: July 2015

    Citation Information

    http://www.seattlechildrens.org/terms-of-use/http://www.seattlechildrens.org/terms-of-use/http://www.seattlechildrens.org/terms-of-use/http://www.seattlechildrens.org/terms-of-use/

  • PUCAI

    Inpatient

    Acute Severe Ulcerative Colitis

    IBD Acute Severe Ulcerative Colitis Medical Management v.2.0

    Return to ED Management

    Inclusion CriteriaKnown ulcerative colitis with Acute Severe Colitis defined as:

    Pediatric Ulcerative Colitis Activity Index (PUCAI) >65 OR

    6 or more bloody bowel movements/day AND one of the

    following: tachycardia, fever, anemia, elevated ESR

    Dehydration, unable to take oral medications or oral

    resucitation

    Exclusion Criteria Toxic megacolon

    Known active infection including CMV; C difficile, or TB

    Crohns disease

    Gastrointestinal (GI) perforation

    Executive Summary Explanation of Evidence Ratings

    Test Your Knowledge Summary of Version Changes

    !Change

    in diagnosis;

    toxic megacolon;

    active CMV,

    C difficile, or TB

    Off

    Pathway

    PUCAI 35-45

    Continue same

    PUCAI >45

    Repeat stool test for C. difficile

    Confirm TB status

    Consult surgeons and stoma

    therapist

    Consider second-line therapy

    with steroid taper

    PUCAI >65 consider colectomy

    Day 3

    Order nutrition consult (if not

    already performed)

    Schedule Sigmoidoscopy. If

    biopsy CMV positive, consult

    infectious disease specialist for

    therapy.

    PUCAI 65

    Start second-line therapy with steroid taper

    Strongly consider colectomy with any significant

    deterioration

    PUCAI 35-65

    Continue methylPREDNISolone IV to day

    10

    Day 6-10 Evaluate PUCAI and labs, monitor progress daily

    PUCAI 65

    Colectomy

    For questions concerning this pathway,

    contact: IBDPathway@seattlechildrens.org 2015, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

    Last Updated: June 2015

    Next Expected Review: July 2015

    Go to Discharge

    Provide Education Ulcerative Colitis: Treating your Child in the Hospital PE1506

    Assess thromboembolism risk, consider prophylaxis

    Establish nutrition plan/support Assess pain

    Establish nutrition plan/support Assess pain

    Assess thromboembolism risk, consider prophylaxis

    Assess thromboembolism risk, consider prophylaxis

    Citation Information

    http://www.seattlechildrens.org/terms-of-use/http://www.seattlechildrens.org/terms-of-use/http://www.seattlechildrens.org/terms-of-use/http://www.seattlechildrens.org/terms-of-use/

  • DISCHARGE PLANNING

    Discharge Criteria

    PUCAI < 35 points (no more than mild disease)

    Afebrile for 24 hours and stable vital signs

    Sufficient oral intake and good hydration

    Pain controlled without IV medications

    Stable hemoglobin without the need for transfusion for at least

    2 days

    If new diagnosis: dietary teaching is complete

    Follow-up scheduled in Gastroenterology Clinic

    Discharge Instructions Print IBD discharge instructions from

    CIS

    Stress that parent should call GI for:

    fever, new pain lasting >4 hours, rectal

    bleeding with most bowel movements

    for 2 days, diarrhea that causes child to

    awaken at night, to not drink enough

    liquid, or restricts activity, or for other

    concerns.

    Return to ED Management

    Evaluate whether ready for discharge

    Definitions5-ASA, 5-aminosalicylic acid

    ASC, acute severe colitis

    CMV, cytomegalovirus

    NPO, nothing by mouth

    PUCAI, pediatric ulcerative

    colitis activity index

    UC, ulcerative colitis of live

    measures

    Home Medication Regimen ConsiderationsSteroid

    Once discharged, convert methylprednisone IV to the same dose (1:1) of

    oral prednisone (max 60mg/day)

    Yes, improved

    Wean to home regimen

    Prepare for discharge

    PUCAI

  • Return to ED Management Return to Inpatient Management

    Objective 1: Inclusion & Exclusion Criteria

    ASC patients can present to ED

    or directly to inpatient ward

    The algorithm only applies to

    patients with known UC

    Exclude acute infections precluding anti-

    inflammatory agent use & toxic megacolon

    Review ED admission criteria

    Based on signs & symptoms

    and pediatric UC activity index

    [Consensus Guideline (Turner, 2011)]

    Admit Criteria PUCAI >65 OR

    6 or more bloody bowel

    movements/day AND one of the

    following: tachycardia, fever,

    anemia, elevated ESR OR

    Dehydration, unable to take oral

    medications or oral resuscitation

    ED Inclusion Criteria Known ulcerative colitis

    Exclusion Criteria Toxic megacolon

    Known active infection incuding

    CMV, C difficile, or TB

    Crohns disease

    Gastrointestinal (GI) perforation

  • Return to ED Management Return to Inpatient ManagementGo to Page 2

  • Return to ED Management Return to Inpatient ManagementGo to Page 1

  • Return to ED Management Return to Inpatient Management

  • Return to Inpatient ManagementReturn to ED Management

    Objective 4: Medical therapy 1st Line

    Methylprednisolone 1.5mg/kg/day max 60mg

    First dose in ED/on admission, subsequent daily 0800 dose

    Patients already on steroids: continue and add stress dose

    First-line therapy

    [Consensus Guideline (Turner, 2011)

    with local expert opinion]

    Acid Blockers

    Standard prophylaxis against gastrointestinal bleeding is

    not recommended

    Possible risk of C difficile

    Risk of hospital acquired pneumonia

    [ Low quality] (Chaibou 1998, Herzig 2006, Hernandez-Diaz 2000, Hyams 2006, FDA, Reveiz 2010, Turco 2010,

    Wilson 2010)

    * Turco 2009

    ** Herzig 2009

    Antibiotics

    Routine antibiotic use is not recommended

    Consider antibiotic therapy for C diff if at risk

    o Antibiotic use 3 days to 3 months prior to colitis symptoms

    o Prior recent history of C diff infection

    May start empiric antibiotics pending results.

    Mild to moderate symptoms: oral metronidazole

    Severe symptoms but tolerating oral intake: oral Vancomycin

    If NPO: IV metronidazole[Consensus Guideline (Turner, 2011)

    with local expert opinion]

  • Return to ED Management Return to Inpatient Management

    Objective 1: Algorithm Inclusion & Exclusion Criteria

    Anti-inflammatory agents may be

    contraindicated in active infections

    Toxic megacolon and GI perforation

    are medical and surgical

    emergencies

    Inclusion CriteriaKnown ulcerative colitis with Acute Severe Colitis defined as:

    Pediatric Ulcerative Colitis Activity Index (PUCAI) >65 OR

    6 or more bloody bowel movements/day AND one of the

    following: tachycardia, fever, anemia, elevated ESR

    Dehydration, unable to take oral medications or oral

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