Audit of Patients with Severe Ulcerative Colitis

Megan Rotherham, Peter Basford | St. Richards Hospital, Chichester

Background

Between 15-25% of patients with Ulcerative Colitis (UC) will require admission for an Acute Severe Ulcerative Colitis (ASUC) flare at some stage during their disease It is potentially life-threatening and requires baseline bloods, stool culture with Clostridium difficile assay, radiological imaging and flexible sigmoidoscopy, with close monitoring after admission A significant proportion of admitted patients are likely to fail to respond adequately to intravenous (IV) corticosteroids and are likely to require medical rescue therapy or surgery

BSG guidelines indicate 67% of patients with ASUC showed a response to steroids, 29% required a colectomy and there is a mortality rate of 1% ASUC patients’ risk of VTE is 2-3 times higher than inpatients without IBD C difficile infection has been associated with a worse outcome in hospitalised IBD patients and needs prompt treatment with Vancomycin in additions to steroids Investigations, prescribing and management plans were assessed according to those deemed necessary by BSG

Aims

The aim of this audit is to review the care of patients admitted at St Richard’s Hospital or Worthing Hospital for ASUC in accordance with the British Society of Gastroenterology consensus guidelines on the management of IBD In addition, the proportion of patients who were visited by specialist teams will be reviewed and the effectiveness of the Oxford Criteria at predicting the requirement for surgery or salvage medical therapy [1]

Results

43 patients were identified with severe UC admitted between July 2019 and July 2020 Of these, 18 (41 9%) were female and 58 1% of patients (25) met Truelove and Witts criteria In total 19 patients required Infliximab and 14 patients required surgery

Within a 24 hour period

• 65% of patients had a Faecal sample sent

• 88% had an abdo x-ray or CT scan

• 19% had a Flexible Sigmoidoscopy

On admission

• 56% of patients received IV steroids

• 51% received VTE prophylaxis

Within 24 hours

• 88% had received IV steroids

• 86% had received VTE prophylaxis

Discussion

BSG guidelines suggest that 67% of ASUC patients show a response to steroids, with 29% having a colectomy and a mortality of 1% This audit found 62 8% did not sufficiently respond to steroids, with 32.6% requiring a colectomy and a mortality rate of 0%.

Truelove and Witt’s Criteria identified 63.2% of the patients who required Infliximab and 83 3% of the patients who required surgery 80% of those who met the Oxford Criteria went on to require Infliximab or surgery

• This accounts for 21% of patients who required Infliximab and 7.1% of the patients who required surgery

Outcomes And Future Projects

• Creation of a "Care Bundle" sticker for medical team to enter into the notes prompting necessary investigations and management on admission and for monitoring.

• Future investigation around Oxford Criteria at 72, 96 and 120 hours to explore impact of weekends on CRP and stool frequency documentation and impact on outcomes

The guidelines for management of ASUC have been set out by British Society of Gastroenterology (BSG) [1] The audit also used Truelove and Witt’s criteria and Oxford Criteria for assessing patient severity [2]

Standards Methodology

Participants were included if they met Truelove and Witt’s criteria or if they were identified as having Severe UC requiring intravenous steroid treatment by a Gastroenterologist between July 2019 and July 2020.

Patients were also assessed according to the Oxford Criteria for the response to steroids at 72 hours Patients medical notes, drug charts, investigations, imaging and any endoscopy or surgery notes were reviewed to source the information

After 72 hours of receiving IV steroids 5 patients (11 6%) met the Oxford Criteria

For the 25 patients who met Truelove and Witt’s Criteria, 12 (48%) patients required Infliximab and 12 (48%) patients required surgery

18 patients did not meet Truelove and Witt’s Criteria, 7 (38.9%) patients required Infliximab and 2 (11.1%) patients required surgery

Recommendations

Additional training with regards to sending stool samples with C. diff testing, prompt IV steroids and VTE prophylaxis all within 24 hours

Improvement must be made in the number of patients who have a flexi-sig within 24 hours

Improvement required in the documentation of stool frequency and CRP testing at 72 hours to monitor steroid response

References

1. Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019;68:s1-s106.

2. Moore AC, Bressler B. Acute Severe Ulcerative Colitis: The Oxford Criteria No Longer Predict InHospital Colectomy Rates. Dig Dis Sci. 2020 Feb;65(2):576-580. doi: 10.1007/s10620-019-05668-

6. Epub 2019 May 15. PMID: 31093812.