Management of severe attacks of ulcerative colitis with new technologies

Barium enema and colonoscopy are contraindicated in severe 
attacks of ulcerative colitis because of the possibility of toxic megacolon and 
perforation. The authors have assessed abdominal ultrasound in 38 patients with 
severe ulcerative colitis. Ultrasound revealed bowel wall thicknesses ranging 
from 3.9 to 9.2 mm (mean 7.7) extending the whole length of the colon, to the 
transverse colon, and to the descending colon, respectively, in 18, 10 and eight 
patients. The degree of bowel thickening was related to the severity of inflammation 
based on clinical, sigmoidoscopic and histological evaluation. In two 
patients, ultrasound showed a thin bowel wall distended without motility, 
suggesting the diagnosis of toxic megacolon (confirmed radiologically). An 
excellent correlation (95%) was found between ultrasound and technetium-99 
scanning. Ultrasound might be a reasonable first investigation in the assessment 
of patients with severe ulcerative colitis.

An llttack is defined as severe when a patient presents with more rhan six bowel movements per day, fever, tachycardia, increase of erythrocyte sedimentation rate greater than 30 and decrease in hemoglohm of at least onethird (I).A mo<lerately severe attack occurs with more than five to ~ix bowel movements daily without evidence of systemic disease.A n intensive intravenous regimen, ie, high dose corticosteroids (prednisolone 60 mg daily), induces remission in about 70% of patients.This treatment, combined with immediate surgery in the patiem who does not respond to me<lical treatment, h as greatly modified the prognosis (2).From current knowledge of the natural history of ulcerative colitis, it is well known that the outcome of an attack of ulcerative colitis is closely dependent on the severity of the inflammatory process, extent of disease an<l response to medical treatment (3 ).Therefore, it ii.important to measure such parameters in severe cases.
When the disease shows such severity, the patient cannot be managed using traditional techniques, such as colonoscopy or double contrast barium enema because of the risk of worsening the course of the disease or precipitating toxic megacolon.Therefore, the assessment of these patients has so far been based mainly on the observations of changes in clinical parameters, eg, the numher of bowel movements and bloody stools, and on the monitoring of plasma parameters.Examining the distal portion of the colon with distal sigmo1doscopy may be helpful, but the results of this latter examination can be masked by concomitant topical treatment.

ULTRASONOGRAPHY AND SCANNING WITH LABELLED LEUKOCYTES
In recent years, fortunately, new diagnostic techniques have been introduced in the management of patients with mflammatory bowel disease (IBO) The first is scintigraphy, which consists of the intravenous administratton of autologous leukocytes labelled with radioisotopes.The techni4ue of scanning with aucologous leukocytes is based on the very simple principle that leukocytes migrate cowards an inflammatory process.Therefore, when these cells are labelled with a radionuclide such as indium-11 L or technetium-99, is possible to map the area of inflammation, nm only in terms of localization, but also in terms of intensity (4)(5).The more recently introduced technique of labelling leuhxytes with technetium-99 offers a substance which possesses the same labelling capacity but a shorter half-life than indium-1 l l (5).
As well, abdominal ultrasonography has been shown to be useful in the management of patients with IBO.This technique has been of value for detecting bowel thickening due wan inflammatory process.It has been used satisfactorily in patients with Crohn\ disease hecause it can show modifications of the intestinal wall such as stricture, and is also of value in detecting abdominal abscesses (6).
So far in patients with ulcerative colitis its use has been rather limited.In the authors' routine clinical experience they noticed that in patients with mild active ulcerative colitis, abdominal ultrasonography was not able to detect any significant change.However, when a patient complains of a severe attack it is possible to observe a generalized thickening of the intestinal wall.Therefore, from these preliminary experiences it seems that abdominal ultrasound examination may be useful for assessing extent of disease, severity of inflammanon and response to medical treatment.

THE AUTHORS' EXPERIENCE
The authors have followed 24 patients with severe attacks of ulcerative colitis, according to the clinical definition, and an additional 18 who were admitted to hospital because of moderately severe attacks.All patients were managed with an intensive intravenous regimen for 10 days and assessed clinically and sigmoidoscopically, at the beginning and end of treatment.According to the above parameters it was judged whether a patient should undergo surgery or continue with medical treatment.
The first day each patient was assessed with an abdominal ultrasound which revealed thickening of the bowel wall and the extent of inflammation.The examination consisted of an abdominal ultrasound examination using a Siemens machine with a 5 MHz detector.During the examination the whole colon was examined, when possible.The extent of inflammation was registered and the thickness of the colonic wall measured with calipers.At the end of each examination it was also possible to obtain a value for disease activity by measuring thickness and multiplying by the number of involved segments in each of the four regions considered ( rectosigmoid, left, transverse and right colon).
On the second day, in two-thirds of patients, a scmtigraph ic examination using leukocytes labelled with technetium-99 was performed.Using chis teclm14ue the extent of disease was revealed and an activity score obtained accord mg to Saverymurtu er al ( 4 ).This score is obtamed in each of the four regions, ie, rectosigmoid, left transverse and ascending colon.
In this preliminary approach the authors tried to find a correlation be, tween the scintigraphic activity score and the ultrasonographic score.This correlation was highly statistically significant ( P<0.001).The ultrasound score showed good correlation with tht clinical activity symptoms.After 10 days the ultrasound examination was repeated and the data analyzed as before.
From a practical point of view, when the thickness of the colonic wall 11' 11 computed before and after treatmentm patients who did respond to mediul treatment, a marked decrease (about JO to 40%) wa~ observed.Apparent~ when the same observation was earned out in patients who did not respond to medical treatment, practically oo change was observed in colonic wall thickness.
A comparison of the data regarding extent of disease obtained by ultra, sound, scintigraphy and operatory specimens was carried out.It appean that scintigraphy is sl ighcly more sens,.
tive than ultrasound in detecting m, flammation in the right colon.However, ultrasound was able to distin, guish between inflammation localized co the left or transverse colon.Ultra, sound examination was also extreme~ useful in detecting toxic megacolon.
From the preliminary data presented here it seems possible to imagine a rok for ultrasound in assessing severity~ disease and extent of inflammation, hit mainly in following patients before and after treatment.From the authors' ex, perience, it seems that ultrasound may provide an objective diagnostic tool.Another important factor is the analysis of cost/risk benefit.Scmt~ graph y cannot be repeated, at least !lC( in the short term, because of risks re, lated to radioactivity.In Italy the cost of a scanning examination is abola US$250 and the time necessary to per, form the test, considering the time fir obtaining cells, 1s about 3 to 5 h.

CONCLUSIONS
From the above considerations it appears that both scincigraphy and ultrasound are extremely useful techniques in patients with severe ulcerative colitis.In particular, ultrasound offers many advantages for the management of this condition.Therefore, in addition to the traditional techniques, lstiruro di Clmica Medica e Gasr:roenterologia, Univenira di Bologna, Bologna, lwly Correspondence and re/mnts: Dr M Cam/)ieri.lsrirmo di Clinica Medica e Grur:roenterologia, Universiw di Bologna, Bologna, lwly CAN J 0ASTR0ENTER0L VOL 4 No 7 NLWEMBER 1990 Ultrasound abdominal exammation.however, can be repeated whenel'cr convenient, and 1s simple to perfonn.C AN J OASTROF.NTEROL VOL 4 No 7 NOVEMllER 1mCosts are relatively low, at US$50 for each examination, and the time required is about 5 to 10 mins.