It is the first and most common of the inflammatory bowel diseases. The frequency of Ulcerative Colitis (UC) is around 6-10 per 100 thousand; The incidence is higher among relatives. Although this situation is interpreted in favor of genetic predisposition, there is no definitive consensus on etiology. Ulcerative colitis is a disease whose cause is unknown, which manifests itself as a chronic, recurrent inflammation of the colon (ulcers, redness and fragility are present), where the emotional state of the patient is important during the course of the disease after it begins, and it is seen only as colon involvement. In UC, the mucosa and submucosa layers of the colon are involved. In almost all cases, the distal colon (rectum) is involved, and the inflammation spreads proximally from there. The terminal ileum (small intestine) is typically not involved. Since the course and prevalence of the disease varies individually, individual treatment approaches are required. After the diagnosis of ulcerative colitis is made (COLONOSCOPE), the extent of the disease should be determined. Particularly, whether the disease is at the level of the descending colon or below, where topical treatment can reach, or is proximal to the descending colon, where topical treatment cannot reach, are the most important questions that need to be answered before treatment planning. Ulcerative colitis has three types of involvement (distal colon involvement, left colon type, whole colon involvement), four types of activity (remission, mild, moderate and severe activity) and four different disease courses (asymptomatic after the first attack, activity gradually getting worse over time, chronic persistent symptoms and chronic recurrent symptoms). Therefore, ulcerative colitis treatment recommendations should be determined according to the patient and the type of colon involvement. In addition, when additional important factors such as extracolon findings, the patient's age, other comorbidities, previous surgeries, intolerance to medications, lifestyle and personal treatment preferences are taken into account, thousands of possible treatment regimens may emerge. The aim of drug treatment in ulcerative colitis is to achieve remission in a short time, improve the quality of life, reduce the need for long-term steroid use, and prevent complications of the disease and the drugs used in treatment. In treatment, an increasing treatment approach from simple to complex has been adopted. Medicine used in treatment While 5-aminosalicylic acid (5-ASA) is considered the main treatment agent, steroids and immunomodulators are considered as treatment intensifiers and infliximab, calcinorin inhibitors [cyclosporin A (CsA) and tacrolimus] or surgery are considered salvage therapy. The risk of colon cancer increases in ulcerative colitis patients starting from 7-10 years, and the risk increases as the duration of the disease increases. For this reason, ulcerative colitis patients should be followed up with repeated colonoscopic examinations, especially in the following years.
DETERMINING THE SYMPTOMS AND SEVERITY OF ULCERATIVE COLITIS
New onset ulcerative colitis or recurrent exacerbation attacks. It usually manifests itself as abdominal pain and bloody and/or mucusy diarrhea. In severe cases, symptoms of weight loss, tachycardia, fever, anemia and abdominal distention are observed. Before starting drug treatment, other causes such as infectious (Clostridium difficile, cytomegalovirus), toxic (antibiotics, NSAIDs), mesenteric ischemia and malignancy should be excluded. The choice of treatment is made according to the degree of disease activity, its prevalence (proctitis, left colon type or pancolonic), the course of the disease, the frequency of relapses, extracolon findings, previously taken medications, side effects of the medications, and the patient's preference. The severity of disease activity can be determined according to the Montreal classification. According to this classification
-Remission: three or fewer defecations per day;
-Mild severity: Having bloody or bloodless defecation at most four times a day. Pulse, fever, hemoglobin level and sedimentation are normal in this group.
-Moderate:There are 4 to 6 bloody defecations per day, and there are no systemic symptoms. .
-Severe: there are more than 6 bloody defecations per day, usually with systemic symptoms (fever more than 37.5 0C, pulse more than 90/minute excessive), anemia (hemoglobin level less than 10.5 g/dL) and increased sedimentation rate (>30 mm/hour).
DIAGNOSIS
Blood-mucus defecation, diarrhea, and abdominal pain are the most important clinical symptoms; Definitive diagnosis is made by colonoscopy and colonoscopic biopsy.
TREATMENT
It varies according to the degree of localization and activation in the colon.
-DISTAL COLITIS (PROCTITIS ) TREATMENT
Mild and moderate cases limited to the rectum should initially be treated only with topical preparations. 5-ASA preparations in the form of suppositories (e.g. 1 g/day) are the first treatment option and provide remission in 31-80% of cases (3). Topical administration of more than 1 g/day of meselamine does not increase the response rate. Although 5-ASA in the form of an enema is an alternative, the medicine given in suppository form is lower in volume and therefore better tolerated by the patient and more effective.
Topical steroids (budesonide 2-8 mg/day and hydrocortisone 100 mg/day). mg/day) is less effective than topical meselamine. If topical treatment does not provide benefit, combinations of topical meselamine and/or oral meselamine (2-6 g/day) with topical steroids are recommended as second-line treatment. When symptoms do not disappear in 2-4 weeks, the patient's compliance with treatment should be reviewed. In cases where symptoms persist, the presence of infectious colitis and spastic colon that may accompany ulcerative colitis should be reconsidered. In the presence of proctitis that persists despite these treatments, the patient should be treated as if it were more widespread and severe colitis.
-TREATMENT IN THE LEFT COLON TYPE
Mild and moderate left colon type ulcerative colitis should initially be treated with topical aminosalicylate and oral meselamine (>2 g/day) (1). With higher doses of oral meselamine treatment (2.4 g/day vs 4.8 g/day), faster clinical improvement was achieved and rectal bleeding stopped faster (16 days vs 9 days, p<0.05), but there was no significant difference in terms of achieving remission (20.2%). vs 17.7%) has been reported (6,7). If rectal bleeding continues despite continuing the combined treatment for 10-14 days, systemic steroids (prednisolone 40-60 mg/day, single dose) should be added to the treatment (1). Although its superiority has not yet been proven, the steroid is usually stopped at 40 mg/day in the first week, 30 mg/day in the second week, and then 20 mg/day for a month, and then the dose is reduced by 5 mg/day per week. Severe left colon type ulcerative colitis is generally considered an indication for hospitalization and initiation of systemic treatment (1).
-ALL TREATMENT IN COLON INVOLVEMENT
In mild and moderate ulcerative colitis, oral treatment should be started alone or together with topical treatment. Patients with clinically mild to moderate colitis and widespread disease should be treated with oral sulfasalazine (4-6 g/day) or oral and topical meselamine as the first treatment option. In cases that do not respond to oral and topical aminosalicylate treatment within 10-14 days or have severe symptoms, oral steroid treatment should be added. In steroid-dependent or steroid-refractory cases, azathioprine (2.5 mg/kg/day) or 6-mercaptopurine (1.5 mg/kg/day) should be added to the treatment to achieve and maintain remission.
>-TREATMENT OF SEVERE ULCERATIVE COLITIS
Severe ulcerative colitis is defined as the presence of more than six cases of bloody diarrhea a day and systemic findings such as fever, tachycardia and anemia. Since there is a risk of developing life-threatening toxic megacolon and perforation, it is recommended that these patients be hospitalized for intensive treatment and observation. In these cases, intravenous methylprednisolone (60mg/day) or hydrocortisone (400mg/day) is the main treatment option to achieve remission. Infliximab (5 mg/kg) can be given in cases resistant to the highest dose of oral steroid and 5-ASA treatment.
Colectomy may be required in 29% of cases with severe ulcerative colitis that require intravenous steroid treatment. Therefore, these cases should be seen by a colorectal surgeon during hospitalization. In cases where the effect of seven-day steroid treatment is not observed, extending the treatment is not beneficial and may negatively affect postoperative wound healing. Therefore, colectomy should be discussed in cases where the general condition worsens or no clinical improvement is observed despite three days of intravenous steroid treatment.
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