News about Medicine - Part 183


Patients with mild to moderate distal colitis may be treated with either oral aminosalicylates, topical mesalamine, or topical steroids. In patients refractory to oral aminosalicylates or topical corticosteroids, mesalamine enemas may still be effective. The unusual patient who is refractory to all of the above agents in maximal doses may require treatment with oral prednisone in doses up to 40-60 mg/day.

The therapeutic plan here is largely determined by the patient’s preference because either oral or topical therapy is effective. Oral therapy with aminosalicylates, either sulfasalazine, olsalazine, or mesalamine, is beneficial in achieving and maintaining remission [1] [9] [10] . Effective doses of sulfasalazine range between 4 and 6 g/day in four divided doses [11] [12] ; for mesalamine, at least 2-4 g/day in divided doses [13] [14] , and for olsalazine 1.5-3 g/day in divided doses [15] [16] [17] [18] , although efficacy of olsalazine in active UC is not conclusively established, perhaps in part because of a confounding dose-related diarrhea. These drugs generally are efficacious within 2-4 weeks [11] [12] [13] [14] [15] [16] [17] [18] and are effective in 40-80% of patients. Intolerance to the sulfapyridine moiety is not uncommon and may result in nausea, vomiting, dyspepsia, anorexia, and headache. More severe, but less common, adverse effects include allergic reactions, pancreatitis, hepatotoxicity, drug-induced connective tissue disease, bone marrow suppression, interstitial nephritis, nephrotoxicity, hemolytic anemia, or megaloblastic anemia. Abnormal sperm counts, motility, and morphology are related to the sulfapyridine moiety and are not seen with the mesalamine preparations. Approximately 80% of patients intolerant to sulfasalazine are able to tolerate olsalazine and mesalamine [9] [18] [19] [20] . However, several of the allergic reactions previously thought to be due to the sulfa moiety have been seen with newer aminosalicylates as well [9] .

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APPROACH TO MANAGEMENTGoals of treatment are directed at inducing and then maintaining remission of symptoms and mucosal inflammation. Once the diagnosis of UC is confirmed, the anatomic extent is assessed endoscopically. The key question to be addressed at this point is whether the inflammation is “distal” (i.e., limited to below the splenic flexure and thus within reach of topical therapy) or “extensive” (i.e., extending proximal to the splenic flexure, requiring systemic medication). Therefore, a delineation of the proximal margin of inflammation, if not achieved on initial evaluation, is desirable at some point in the management of the case once the patient’s condition permits. Read the rest of this entry »


RECOMMENDATIONS FOR DIAGNOSIS AND ASSESSMENTIn a patient presenting with persistent bloody diarrhea, rectal urgency, or tenesmus, stool examinations and sigmoidoscopy and biopsy should be performed to confirm the presence of a colitis and to rule out infectious causes. Characteristic endoscopic and histologic findings with negative evaluation for infectious causes will suggest the diagnosis of ulcerative colitis.

The diagnosis of UC is suspected on clinical grounds and supported by the appropriate findings on proctosigmoidoscopy or colonoscopy, biopsy, and by negative stool examination for infectious causes. Infectious etiologies of colitis can produce clinical findings indistinguishable from idiopathic UC, so microbiologic studies for bacterial and parasitic infection, as well as serologic testing for ameoba when clinical suspicion is high, should be performed in each new patient and in patients with stable symptoms who develop a severe exacerbation. Similarly, patients who have had recent antibiotics, or have recently been hospitalized, should have stools examined for Clostridium difficile.

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Ulcerative Colitis Practice Guidelines in Adults

Ulcerative colitisINTRODUCTION

Ulcerative colitis (UC) is a disorder characterized by diffuse mucosal inflammation limited to the colon. UC is usually a chronic disease which involves the rectum and may extend proximally in a symmetrical, circumferential, and uninterrupted pattern to involve parts or all of the large intestine. The hallmark clinical symptom is bloody diarrhea often with prominent symptoms of rectal urgency and tenesmus (painful straining at stool). The clinical course is marked by exacerbations and remissions, which may occur spontaneously or in response to treatment changes or intercurrent illnesses [1] [2]. Ulcerative colitis affects approximately 250,000 individuals in the United States with an incidence of 2-6 per 100,000 people per year; the prevalence has remained relatively constant over the last five decades.

Henoch-Schönlein Purpura

Henoch-Schönlein Purpura

Henoch-Schönlein purpura, also referred to as anaphylactoid purpura is a systemic vasculitis syndrome characterized by palpable purpura (usually distributed over the buttocks and lower extremities), arthralgias, gastrointestinal signs and symptoms, and glomerulonephritis. It is a small vessel vasculitis.

Incidence And Prevalence

Henoch-Schönlein purpura is usually seen in children, age from 4 to 7 years; however, the disease may also be seen in infants and adults. It is not a rare disease, accounting for approximately 5 and 24 admissions per year at one pediatric hospital. The male to female ratio is 1.5:1. A seasonal variation with a peak incidence in spring has been noted.

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Dermatomyositis And Polymyositis – Treatment

treatmentGlucocorticoids in high dosage is the accepted treatment for severe dermatomyositis-polymyositis, though there is no controlled trial to prove its effectiveness. Prednisone is generally started at a dose of 1 to 2 mg/kg body weight per day (60 to 100 mg/d for adults). Improvement may begin within 1 to 4 weeks, though in some patients treatment may need to be continued for 3 months before improvement occurs. When improvement is noted, the daily dose may be reduced by 5 mg every 4 weeks. Repeated manual muscle testing and serum CK determinations should be performed to ensure that the myositis does not relapse. At about 40 mg/d, the schedule is changed gradually to 80 mg every other day in order to reduce the incidence of side effects. There is some evidence that the use of alternate-day glucocorticoids from the outset may be effective, particularly in patients with milder disease. Adults with acute to subacute dermatomyositis-polymyositis tend to improve more rapidly than those with chronic polymyositis; children also respond in most cases. If the dose is reduced too rapidly, or to too low a level, relapse will occur, necessitating return to high dosage. Prednisone therapy may have to be continued for several years, but an attempt should be made every year to withdraw the therapy from patients who are clinically stable in order to determine if the disease is still active.

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Dermatomyositis And Polymyositis – Diagnosis

Dermatomyositis Polymyositis DiagnosisPatients with dermatomyositis who have the characteristic skin rash, muscle weakness, EMG changes, and elevation of serum CK may not require a muscle biopsy to confirm the diagnosis. In the case of idiopathic polymyositis, however, a firm diagnosis must be based on the presence of a typical clinical picture, a typical EMG, elevation of serum CK, and a diagnostic muscle biopsy. All four of these criteria are required to be certain of the diagnosis, since inflammatory changes may occasionally occur in other myopathies (e.g., facioscapulohumeral muscular dystrophy) and in other connective tissue disorders without clear muscle weakness. However, in fewer than one-third of cases of polymyositis are ALL these criteria satisfied. It may be particularly difficult to obtain a diagnostic muscle biopsy because of the patchy nature of the disease. Thus, a therapeutic trial of glucocorticoids should be given when full investigation of a patient with significant disability leaves a diagnosis of “possible polymyositis,” usually because of a nondiagnostic muscle biopsy.


So Many Advances in Medicine, So Many Yet to Come