Postgrad Med J: first published as 10.1136/pgmj.44.515.696 on 1 September 1968. Downloaded from Postgrad. med. J. (September 1968) 44, 696-707. The medical treatment of ulcerative colitis GEOFFREY WATKINSON Consultant Physician to the York Hospitals THE ADEQUATE treatment of any illness depends (i) To terminate the acute colitic attack or primarily upon a knowledge of its aetiology and relapse as quickly as possible. in a chronic relapsing illness, such as ulcerative (ii) To attempt by some form of maintenance colitis, an awareness of its natural history and therapy to prevent relapses or complications of complications. While the final cause of ulcerative the disease. colitis remains obscure, increasing knowledge of (iii) By a knowledge of factors known to possible causal factors and of the prognosis of influence the natural history and prognosis of the condition has markedly influenced its treat- colitis, to recognize that medical treatment has ment in recent years. failed to induce remission or to prevent relapses When colitis was thought to be of bacterial or complications and to refer the patient for origin specific sera were prepared but proved of urgent or elective surgery. no lasting value. Similarly, no effective agents to The physician has to accept, as Bargen (1961) Protected by copyright. inhibit mucinases have been evolved. Enthusiasts has emphasized that 'control' of colitis is far for the hypothesis that colitis is due to food more likely than 'cure' and that the patient must allergy have advocated the use of milk-free diets be supported through long weeks, months or in colitic patients with apparent benefit (Andre- years of chronic and often recurrent illness. This sen, 1942; Wright & Truelove, 1965a, b). Attempts is best done by a patient and persevering phys- to suppress supposed autoimmune reactions have ician who works in close association with a sur- been made with corticosteroids used orally, topic- geon interested and skilled in the difficult colonic ally or parenterally, by non-specific anti-inflam- surgery that colectomy in an acutely ill colitic matory agents, such as sulphasalazine or more patient may demand. Throughout a combined recently by immunosuppressive agents. Physicians medico-surgical approach should be adopted impressed by psychosomatic factors in the illness both in the day-to-day management of acute have advocated the use of psychotherapy, of attacks and through months and years of follow- sedatives and antidepressant drugs and even up of the chronic case at a colitis clinic run leucotomy to control the condition. jointly by a physician and surgeon. It has been http://pmj.bmj.com/ Assessment of the value of any therapeutic suggested that a psychiatrist should complete the measure proves difficult in a disease which varies team to cope with the frequent psychosomatic greatly in severity and extent, not only from problems which afflict these patients. While this is patient to patient but in the same individual from a debatable issue such a team obtained excellent attack to attack, making rigorous controlled results in the paediatric clinic of a Michigan trials of any measure necessary in large groups hospital (McDermott, John & Finch, 1964). of colitic patients before its values can be accep- ted. Treatment of the acute attack on September 28, 2021 by guest. Increasing knowledge of the nutritional and The measures used in treating severe initial biochemical problems encountered in these colitic attacks and relapses are summarized in patients, together with the introduction of more Table 1 below. potent drugs, such as sulphasalazine and cortico- steroids and the wider use of surgery, have mater- Rest ially improved the prognosis of ulcerative colitis Bed rest is recommended for any colitic re- in the last two decades. lapse and early hospitalization for patients with severe diarrhoea, copious bloody stools, fever Principles of medical treatment anaemia and weight loss. More adequate rest will The duties of a physician treating a patient be aided by the administration of sedative and with ulcerative colitis can simply be stated: tranquillizing drugs, such as phenobarbitone and Postgrad Med J: first published as 10.1136/pgmj.44.515.696 on 1 September 1968. Downloaded from Medical treatment of ulcerative colitis 697 amylobarbitone. In more anxious or obsessional given and if used in dosage sufficient to produce patients meprobamate, chlordiazepoxide or mild side-effects will often control both diarrhoea diazepam can be tried and where agitation is and cramping abdominal pains. They are con- complicated by nausea and vomiting, drugs traindicated in patients with glaucoma or previous such as promethazine hydrochloride or chlorpro- urinary retention and if given in excessive dosage mazine can be used. Adequate sleep is essential to severely ill patients may induce intestinal often making hypnotics, such as chloral hydrate, atony simulating a toxic megacolon. amylobarbitone, pentobarbitone or gluthemide, Belladonna given as the tincture or in a sus- necessary. tained release tablet (Belladenal retard or Donnatal) can be used or one of the numerous TABLE 1 synthetic anticholinergic drugs available, such as Medical treatment of ulcerative colitis propantheline bromide, poldine methylsulphate, methscopolamine bromide or penthionate brom- REST ide, exhibited. Bed rest-hospitalization For the control of copious diarrhoea the use Sedative and tranquillizing drugs Hypnotics of opiates is justified provided it is realized that these COLONIC REST drugs have addictive properties, may mask Parenteral feeding perforation or worsen ileus and, therefore, Fluid diet should only be prescribed for short periods and Low-residue, high-protein diet tapered off as soon as possible. Codein phosphate Antispasmodic and antidiarrhoeal drugs tablets, tincture of opium or tincture of chloro- MAINTENANCE OF NUTRITION AND OF FLUID AND form and morphia can be given. Lomotil is a ELECTROLYTE BALANCE Replacement of fluid useful proprietary tablet combining a codein Mineral replacement salt, potassium, magnesium, calcium derivative diphenoxylate hydrochloride with Protected by copyright. Vitamin supplements atropine sulphate. Parenteral feeding Thickening of the stools with bulk-forming Anabolic agents laxatives seems to improve sphincter control while CORRECTION OF ANAEMIA Oral, parenteral, intravenous iron a few patients with proctocolitis may need mild Blood transfusion laxatives as they are in fact constipated. Hydro- DIET philic agents, such as psyllium seeds or methl- Low roughage, high-protein diet cellulose, are used with or without mild laxatives, Milk free diet on occasion such as milk of magnesia, liquid paraffin or stan- ANTIBIOTICS dardized senna. Used with caution, best given parenterally Penicillin and streptomycin Ampicillin, chloramphenicol Maintenance of nutrition and of fluid and electro- Neomycin lyte balance MORE SPECIFIC REMEDIES In acute fulminating attacks gross dehydration Sulphasalazine and profound electrolytic and metabolic imbal- http://pmj.bmj.com/ Orally ances may develop making it vital that such cases Topically Coticosteroids be managed in hospital where adequate bio- Parenterally chemical facilities are available together with the Orally trained nursing and house officer staff to cope Topically with the intensive care which these cases may TREATMENTS UNDER EVALUATION require. Immunosuppressive agents In severe attacks gross dehydration with a Rectal hypothermia on September 28, 2021 by guest. Leucotomy hyponatraemic, hypokalaemic acidosis may develop making it necessary to rapidly correct these deficiencies with intravenous 5% dextrose, Colonic rest 0-9% sodium chloride (150 mEq/l) or I M-lactate Colonic rest is achieved by dietary means and and adding potassium chloride 1-5 g (20 mEq) by various antispasmodic and antidiarrhoeal to each 500 ml of infusion fluid. Potassium deple- drugs. In the severely ill patient with continuous tion may be profound and up to 80 mEq daily diarrhoea complete withdrawal of oral fluid and may have to be given. Magnesium depletion may feedings is justified, the patient being maintained develop and is becoming more widely recognized by parenteral fluids. Later a fluid diet and finally as facilities for its estimation become more a low residue high protein diet are given. widely available. A wide variety of antispasmodic drugs can be Subsequently additional salt and potassium can Postgrad Med J: first published as 10.1136/pgmj.44.515.696 on 1 September 1968. Downloaded from 698 Geoffrey Watkinson be given orally as enteric coated tablets or as Diet effervescent tablets (1 g=6-5 mEq) of potassium. Rapid wasting occurs in both acute and chronic Reports that such tablets may cause intestinal attacks with hypoproteinaemia, vitamins and ulceration have led to the use of liquid prepara- nutritional deficiencies. It is therefore important tions of the chloride (6 5 mEq/g), the citrate that the patient eats as much of a high-protein (9-2 mEq/g) or the gluconate (20 mEq/ 15 ml). low-residue diet as his condition allows supplying Unfortunately, many of these preparations are 2500-3500 cal daily with 100-150 g of protein unpalatable and may cause diarrhoea in which presented as attractively as possible. This diet is case a slow release tablet incorporating 600 mg most widely used in ulcerative colitis. of potassium chloride (8 mEq) in a slow release The role of milk allergy in the pathogenesis of wax core is administered in a dosage of four to colitis was first suggested