1、The Clinical Application of Corticosteroids in Ulcerative Colitis,rui nan Wang,Two parts,The introduction of Ulcerative colitisThe clinical application of Corticosteroids in Ulcerative colitis,Ulcerative colitis,Definition:Chronic non-specific colitisInflammation of the mucosa and submucosa of the l
2、arge intestine,Features:,diarrhea with feces containing mucus, pus and blood, abdominal pain and tenesmus; and recurrence is commonMostly seen in 20-50 years of age, and in EuropeLess common in China,Infection,Environmental factors,Genetic susceptible,Immune & inflammatory system,Etiology and pathog
3、enesis,Location: rectum and sigmoid colon, then descending, transverse or pan-colon, even terminal ileumMucosa diffused inflammation with edema, congestion and local bleedings.,Pathology,Infiltration of lymphocytes, plasma cells, eosinophilic cells and neutrophilic cells in mucosaCryptic abscess and
4、 superficial ulcersInflammatory polyps or pseudopolyps;,UC,UC,Cryptic abscess in UC,Clinical Manifestations,Symptoms: diarrhea abdominal pain, others : tenesmus, anorexia, nausea and vomiting Signs: tenderness in the left hypogastrium and rebound tenderness,Manifestations of digestive system,Systemi
5、c manifestations,fever,tachycardia,Anemia, malnutrition, volume depletion, disturbance in acid-basebalance and hypoalbuminemia in advanced patients,Extra-intestinal manifestations,erythema nodosum, arthritis, ankylosing spondylitis, iritis，episcleritis, conjunctivitis, ulcers of oral mucosa, chronic
6、 active hepatitis and so on.,erythema nodosum,A.course classificationinitial typechronic relapse typechronic permanent type acute and fulminant type,Clinical classification,UC,B.Extent classification (1) mild type (2) moderate type (3)severe type,Classification,UC,C.range classificationProctitis or
7、proctosigmoiditis:40-50%Left-sided or intermediate colitis :30-40%Pancolitis:20% D.period classificationActive phaseAlleviative phase,Classification,UC,UC,endoscopic examination,Diseased mucosa: hyperemic and edematous, blood vessels not clear-cut, mucosa erosions and multiple shallow ulcers; rough,
8、 fragile, bleeding easily granular, pus; pseudopolyps seen,Mucosa irregularity, saw-tooth like, loss of haustrations, shortening of colon and pseudopolyps formationContraindicated in fulminant type,UC,Barium enema,typical symptoms+one of endoscopic appearances and biopsy (or one of x-ray barium enem
9、a signs)+elimination of other alike disease Notice:1.symptoms are not typical,while endoscopic appearances are typical-diagnosis 2.symptoms are typical, while endoscopic appearances are not typical-suspect,Diagnosis,Treatment,General treatment,Drug treatment,Sulfasalazine,Corticosteroids,Immune inhi
10、bitor,First choice,Severe patients,Surgical therapy,Indications: abscess formation, canceration, perforation, fistula, mega-colon and refractory colitis, failure of medical therapy etc,Second part,The clinical application of Corticosteroids in Ulcerative colitis,Finding,CORTISONE IN ULCERATIVE COLIT
11、IS FINAL REPORT ON A THERAPEUTIC TRIAL,BRITISH MEDICAL JOURNAL On OCTOBER 29 1955,S. C. TRUELOVE, M.D., M.R.C.P. AND L. J. WITTS, M.D., F.R.C.P.,Conclusion,the patients receiving cortisone enjoyed a clear-cut advantage over the patients on a dummy preparation. About two out of every five patients on
12、 cortisone therapy were in clinical remission at the end of six weeks treatment, compared with less than one out of every six patients receiving the inert therapy.,Among the patients treated with cortisone those in their first attack have fared somewhat better than those in relapse.,How to decide th
13、e dose of Corticosteroids,The American Journal of GASTROENTEROLOGY,Ulcerative Colitis Practice Guidelines in Adults,by American College of Gastroenterology Practic Parameters Committee,Ulcerative Colitis Practice Guidelines in Adults,Oral prednisone shows a dose response effect between 20 and 60 mg
14、per day , with 60 mg per day modestly more effective than 40 mg per day but at the expense of greater side-effects .,Ulcerative Colitis Practice Guidelines in Adults,No randomized trials have studied Corticosteroids taper schedules; most recommendations have advised 40 60 mg per day until significan
15、t clinical improvement occurs and then a dose taper of 5 10 mg weekly until a daily dose of 20 mg is reached. At this point tapering generally proceeds at 2.5 mg per week.,The therapeutic plan is determined by the Patients condition and preferences,severe and fulminant type,For patients who suffer f
16、rom severe and fulminant type of UC ：intravenous injection Corticosteroids is First choice , recommend dosage hydrocortisone 300mg or meprednisone 60mg。,mild and moderate type with largely lesion,For mild and moderate patient, First choice oral Sulfasalazine ，while it is not effective，recommend oral
17、 prednisone 2060 mg/d,mild and moderate type with Distal lesion,Corticosteroids topical therapies,Effect of topical administration of budesonide and tranditional corticosteroids on active distal ulcerative colitis or proctitis,Shang hai Jiao tong University School of Medicine,Research from,Conclusio
18、n,The effects of budesonide and traditional corticosteroids on active distal Ulcerative colitis or Proctitis are similar.However, budesonide maybe Preferable to traditional corticosteroids ,since its inhibitory effect on Plasma cortisol level is lower than traditional corticosteroids.,adverse effect
19、s,Such as cushingoid features, emotional and psychiatric disturbances, infections, glaucoma.Complicationsinclude gastroduodenal mucosal injury, impaired wound healing, and metabolic bone disease.,steroid-dependency,Although short term control of symptoms can be achieved with steroid treatment, follo
20、wed by recurrence during alleviating dose or stopping administration this pattern of drug response，known as steroid-dependency,The therapeutic plan for steroid-dependency,Azathioprine 2-2.5mg/kg*dCyclosporin therapy for severe ulcerative colitisInfliximab could not only maintain the clinical remission in UC patients，but also decrease the colon resection rate for patients with moderate to severe refractory UC,Else therapies,intestinal stem cells antibiotics If failure of medical therapy ，the Surgical therapy should be taken.,The end,
