Toxic Megacolon in Crohn’s Colitis
Savio George Barreto, Shailesh V. Shrikhande in Dilemmas in Abdominal Surgery, 2020
Toxic megacolon is a condition traditionally characterized by gross colonic distension in the setting of severe colitis culminating in septic shock. In the acute scenario, biopsies from flexible sigmoidoscopy often cannot distinguish between ulcerative colitis or Crohn's disease. Surgery remains the mainstay of managing toxic megacolon due to inflammatory bowel disease and is often a life-saving procedure. The initial management of a patient with suspected toxic megacolon begins with securing the airway, providing supplemental oxygen, assessing the hemodynamic stability and cognitive state. An erect chest X-ray, with the inclusion of both domes of the diaphragm, is warranted to confirm the same before proceeding to emergency surgery. The findings of erythema, granularity, loss of submucosal vessels with deep ulceration, and spontaneous bleeding with contact or air insufflation often portends the risk for surgery. Tertiary centers often have a subspecialist colorectal surgical unit that must be involved early, should the need for surgery arise from failed medical management.
The Large Bowel and the Anal Canal
E. George Elias in CRC Handbook of Surgical Oncology, 2020
Cancer of the large bowel is one of the leading causes of death in the country. Polyps and large bowel cancer in populations are closely associated in geographical and anatomical distribution. High risk factors have been identified among patients with chronic ulcerative colitis. These include long standing colitis, onset of the disease at an early age, severe first attack, and continuous symptoms. Computerized tomography scan of the abdomen is a great diagnostic tool especially in patients that present with large bowel lesions, bowel obstruction, or advanced stages of the disease. Once the diagnosis of adenocarcinoma of the large bowel is made, the stage of the disease at the time of diagnosis carries the most significant prognostic factor. Cancers of the anal canal are rare lesions and constitute less than 5% of all rectal cancers. These cancers are divided into two groups according to their site of origin as the therapeutic approach as well as the prognosis differ.
Proctocolectomy for Inflammatory Bowel Disease - Open
Stanley M Goldberg in Operative Surgery of the Colon, Rectum and Anus Operative Surgery of the Colon, Rectum and Anus, 2015
Total proctocolectomy with end ileostomy was for many years the procedureof choice for inflammatory bowel disease (IBD) patients who required surgery.However, additional options have evolved over the past 40 years, including colectomy with ileorectal anastomosis (which should generally only be used in patients with rectal sparing), restorative proctocolectomy with continent ileostomy, or reconstruction with an ileal pouch-anal anastomosis (IPAA). The latter has become the most frequently performed procedure for patients with ulcerative colitis (UC) who require surgery. Total proctocolectomy was initially conceived as a four-stage procedure (ileostomy, right hemicolectomy, left hemicolectomy, and abdominoperineal resection) eventually becoming a two-stage procedure (total abdominal colectomy and proctectomy) and, finally, the modern one-stage procedure due to advances in anesthesia, antibiotics, and surgical technique.
Tofacitinib for the treatment of ulcerative colitis
Published in Expert Review of Clinical Immunology, 2018
Agnès Fernández-Clotet, Jesús Castro-Poceiro, Julián Panés
Introduction: New generations of small molecules are being developed for the treatment of ulcerative colitis. Among them, tofatinib (a Janus kinase (JAK) inhibitor) has demonstrated efficacy for inducing and maintaining remission and achieving mucosal healing with a reasonable safety profile. Oral administration is attractive for patients and lack of immunogenicity represents an advantage over biologic drugs. Areas covered: This review discusses the molecular aspects of the JAK-STAT pathway; the mechanism of action of tofacitinib pertinent to ulcerative colitis and the evidence on the efficacy of tofacitinib for achieving clinically relevant outcomes, including clinical remission, mucosal healing, and normalization of quality of life, as well as safety aspects with special attention to adverse events related to the mode of action of the drug. Expert commentary: Tofacitinib will be the first drug on the class of JAK inhibitors to be available for treatment of ulcerative colitis. The efficacy of the drug, with a rapid onset of action even in cases of severe colitis, oral administration, and possibility to use the drug intermittently without generating immunogenicity, will bring about a redesign of current treatment paradigms for ulcerative colitis.
Advances in endoscopic imaging in ulcerative colitis
Published in Expert Review of Gastroenterology & Hepatology, 2015
Gian Eugenio Tontini, Luca Pastorelli, Sauid Ishaq, Helmut Neumann
Modern strategies for the treatment of ulcerative colitis require more accurate tools for gastrointestinal imaging to better assess mucosal disease activity and long-term prognostic clinical outcomes. Recent advances in gastrointestinal luminal endoscopy are radically changing the role of endoscopy in every-day clinical practice and research trials. Advanced endoscopic imaging techniques including high-definition endoscopes, optical magnification endoscopy, and various chromoendoscopy techniques have remarkably improved endoscopic assessment of ulcerative colitis. More recently, optical biopsy techniques with either endocytoscopy or confocal laser endomicroscopy have shown great potential in predicting several histological changes in real time during ongoing endoscopy. Here, we review current applications of advanced endoscopic imaging techniques in ulcerative colitis and present the most promising upcoming headways in this field.
Vedolizumab for the treatment of ulcerative colitis
Published in Expert Review of Clinical Pharmacology, 2014
Svend T Rietdijk, Geert R D’Haens
Ulcerative colitis is a chronic inflammatory disease of the large intestine that often develops in the young. A few new treatment options have become available in the past decade, but management of a large proportion of patients still remains challenging because of side effects, unresponsiveness and cost. A novel strategy targeting trafficking of immune cells to the sites of inflammation involves reducing expression or binding of adhesion molecules to integrins. Natalizumab was the first therapeutic antibody blocking infiltration of leukocytes, but because of lack of selectivity to the gut and associated risk of progressive multifocal leukoencephalopathy, it will probably never be tested in ulcerative colitis. In this article we discuss molecules that block leukocyte trafficking to inflamed bowel that have been tested in ulcerative colitis. Because of favourable efficacy and safety data, we will review the development, pharmacology and clinical data of vedolizumab, a gut-selective α4β7 antibody, in depth.
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