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Ulcerative Colitis: The recommended line of Mx

Mar 09 | 2:00 PM

Over the last decade, the treatment of acute severe ulcerative colitis has progressed from being solely limited to intravenous steroids or colectomy to include colon rescue medicines such as cyclosporin and infliximab. It is still a medical emergency that necessitates hospitalisation and treatment from a multidisciplinary team that includes a gastroenterologist and a colorectal surgeon. The emphasis on time-bound decision making has been a paradigm shift in management, with the goal of lowering the mortality rate to less than 1%.

[Music] good evening everyone this is dr brishali from netflix and i would like to welcome you for today's session on ulcerative colitis the recommended line of management we have with us today dr manoj goda and consultant gastroenterologist and a senior gastroenterologist to gujarat research and medical institute ahmedabad he has over four decades of experience now that's a lot of experience and you all are surely going to learn a lot from him today uh he apart from being a very uh senior gastroenterologist he also likes teaching residents nurses and paramedical so i'm sure this academically inclined person will be teaching a lot to you he also has a few publications to his name like bedtime gastroenterology short notes in gastroenterology in which he has explained about the interesting cases he has seen also it's about it has a special reference to practitioners in indian subcontinent so without further much delay in the session i'll hand it over to you sir right good evening uh everyone thanks for joining in at at this time i'm dr manoj vara from the bug and practicing clinicians so my talk will be more uh leaning towards the practical aspect right the colitis as you know i mean many people come and ask me is is there anything new and for a number of years i think we say that no we don't have many things for for newer things for you um and still this elastomer fibromyalgia seed and steroids are the core of the treatment of ulcerative colitis so i will briefly mention them in in my talk and how to use them to get maximum benefit and then talk about the exciting newer research and upcoming drugs for encephalitis so celestophine as we all know is still used in oxidative politics it's cheaper and it was a chance finding that in 40s they tried to treat something else and colitis got better so uh serious pyramid got approved for uh certicolitis and uh they found out that sulphine the cellulosopalate is no longer required so it was removed and you have pure 5 amino salicylic acid which is available uh even today and it's very useful steroids came in 1955 and still they are the mainstay of severe treating severe ulcerative colitis for these drugs to work optimum i think you should know the extent of colitis obviously so this uh this cartoon uh tells us about the extent of colitis at one end the left and upper left corner you have proprieties only 10 centimeters or so are involved then you have protrusive modities where up to 30 35 centimeters then you have left sided colliders where colitis extends up to splenic fraction which is at 50 centimeters then subtotal colitis in colitis now if you see a hand-drawn cartoon on the right side you will see that uh for proptities it's ten centimeters and mesa called suppositories or antophomoneema or any kind of form anymore suppose it will the effect of these drugs will not extend beyond 10 centimeters so if you have proptitis then probably you can try with suppose it is only and there are n number of papers which suggests that you may be able to get away with only per rectal treatment same with the form form is more expensive a little bit difficult to administer but suppositions are very easy or you have rectal symptoms predominantly rectal symptoms suppose you have total colitis going right into the cecum but you have probably pyramid rectal symptoms and what i mean by rectal symptoms is tanismus that as soon as you you finish your opening your bowels you feel that you have to go again and there is heaviness in the perineum and there is urgency you have to rush to the toilet and extreme of urgency is incontinence if you have these symptoms predominant this symptom even with any grade of colitis you may still use suppositories and all form or you can use both because they both work differently and control the symptoms better so if you have rectal symptoms or properties you may use these drugs but these drugs form and suppose it is will not reach 15 20 25 centimeters if it's a proctosigmoid and then your standard enema in a left letter or right little position depending upon how which handed you are it could be given and this medication can be used solely or to supplement the oral drugs and they will reach 15 20 25 centimeters at the most um but if your left sided colitis your standard enema may not reach there and in that circumstance you may have to increase the volume of the fluid that you administer and to put the patient in head down position and give it slowly so that there is enough volume to reach spinning flexion and since there is a larger volume the rectum is very irritable in ulcerative colitis it will just expel everything out in no time if you are fast enough even when we are doing colonoscopy and the rectum is totally empty patient will say that i will have to evacuate my bowel so it is very sensitive so give it slow head down and patient should lie at least for 30 minutes uh or more if he can and then your medication may reach up to left uh splenic fracture up to 50 centimeters so this is for a gastroenterologist it's very important to know that what are the predominant symptoms are there any rectal symptoms and to what extent the colitis extent for subtotal colitis or total colitis your form or enema or suppose it is will not reach and you will have to supplement these drugs with oral drugs the problem with oral drugs is you give it at one end and it has to act at the other end and in proctitis it is the last part so you you get more side effects than effects so we try to find out to what extent these colitis uh reach and what drug what's what are predominant symptoms what's bothering them and whether you have to give only oral only rectal or a combination of both depending upon the type of symptoms and the external to the disease so this is about uh standard drugs uh which are cellulosophile and still use super 5 amino silica acid and steroids and then you have uh azathioprine and cyclosporine and tacrolimus and what have you but basically they are used to uh spare uh you uh with side effect of steroids so they in their own they are not medications to be used solely in ulcerative colitis uh so this was the scenario till say a few years ago and we were frustrated just as our patients were but now this scenario is changing and i will take you through a very exciting journey and see how research has helped and what more is uh promised in future so for that we go to next slide right now this looks a very intimidating diagram but it's very easy at the top end you have a colonic mucosa and colonic lumen will have a lot of bacteria this bacteria are there for billions of years and they have learned to live happily with the colonic epithelium and in the process in the bargain they obviously generate some important nutritious substances also but one important thing they do is to protect the colonic epithelium from nasty bacteria bad bacteria so that is very important for health of colonic epithelium uh and we'll discuss why it is important in a short while then a colonic epithelium has tight junctions they don't allow any bad bacteria or antigens to go into them inappropriate so tight junction is also a requirement for healthy colon now even then some bad bacteria or antigen will leak into lamina propria which is shown here in the middle then in lemon appropriate they encounter some resident security agents like if you are going in a mall you will see couple of security agents sitting in chair with their lucky danda in the hand most of the time these days they look in their mobile and they don't have any idea who is coming and who is going but in in good old days they used to scan the audience the the incoming population and find out who they should tackle so these are resident security agents are macrophages and dendritic cells macrophages and dendritic cells will identify the nasty antigen or virus or what have you and they will produce some degree of uh response some some chemicals will be secreted some t lymphocytes will be activated and most of the time this mild interaction between resident security agent and foreign body will be terminated and no harm will come healing will take place and nobody will be any wiser but in colitis there is exaggeration of this response remember this will come to this again and again there is exaggerated response so there is a lot of inflammation a lot of cytokines chemicals and uh interleukins and all are produced and sometimes they they perceive that if they need more help they need more help to counter this information so a message goes from t cells activated t cells to lymph nodes that we need more security agents to help us so this message will convey to lymph nodes lymph nodes will in return will send some leukocytes to help these inflammatory agents or these nasty bacteria and they open up a channel this channel will allow lymphocytes and wbcs to come out go into vascular epithelium and reach the site of this fight as soon as they reach their site they they get out of the vascular epithelium by another receptor and go into lamina propria and they've joined the fight so there is more recruitment and there is a lot of ulceration and inflammation in case of colitis so this is the basic pathology of ulcerative colitis so at each stage if you can control this hyperinflammation colitis will heal so if you want to treat colitis in a better way you have to consider common cells microflora that how can it be normal and do its job then you have to make sure that epithelial barrier is very tight and it's not leaky that antigen recognition is not exaggerated immunological response is not exaggerated leukocyte recruitment is just adequate to control these invading agents and then there are genetic factors about which we can't do much at the moment so these are the points we should consider in in treating ulcerative colitis so the aim is to restore the microbiota tightening the leaky junction and increasing production of mucus controlling immune disregulation controlling leukocyte trafficking and destroying epithelial tight junctions so people have understood the pathogenesis now and at each point there is an opportunity to control ulcerative colitis in a better way you remember many years ago we had b virus and c virus and we were wondering how on the earth we can control this but newer drugs have come and foresee its miracle we understood the pathogenesis and drugs were found out to block each and every step and now in 12 weeks you can get rid of hepatitis c so same thing is probably going to happen in ulcerative colitis in next few years let's see this is the first phase of the newer therapy is restoring the microflora now you know about probiotics and they came with big bang unfortunately we have still not got the the sixth sense about which probiotic and in what those will work so you have your vsl3 and busy lake and broadway deck and what have you but they do work but in tandem with other drugs i mean i would not dare to treat my patient with ulcerative colitis only with probiotics of course they help uh and in pouch it is probably they they can work alone also but in other way otherwise uncertain colitis they do help but it's a good concept and probably in the future you will see that probiotics in a different author will be more effective than what it is today then to restore microbiota microbiota or commensals flora we have this newer conceptual bacterial transplant here you take all the bacteria good medium and not so good bacteria and mass from a healthy person culture them in laboratory and put them back so all the goodness of commensulflora will be transported into a new patient and this works wonders in clostridium difficile or antibiotic associated diarrhea and there are reports coming from western countries and some from india also that fecal bacterial transplant will be helpful in some cases of ulcerative colitis so a lot of work still needs doing in this case but these are the two new concept and at least you can use probiotics in a selected case fecal bacterial transplant as and when it it is easily available it will be used so that is one approach that is very exciting and it has just started coming in the routine practice and we'll see in next few years that some combination of this will be very useful uh next is as soon as the bad bacteria or antigen get into lamina appropriate the security agents macrophages and dendritic cells get activated and this activation is rather very enthusiastic you know instead of latitude you are shooting with bullets so a lot of damage will be done so what can be done to reward them from firing bullet into literature is jack antagonish genus kinase group of enzyme are required to produce these cytokines this chemicals uh and if you block it these chemicals will be produced but in a lesser amount so the perpetuum or exaggerated response inflammation edema ulceration will be controlled so jack antagonist is a new concept and this is the way it works uh probably we are not interested but generous kindness signals stimulate immune cells to produce inflammatory proteins cytokines and it carries on the inflammation it it allows inflammation to go on and on so if you control these jack enzymes probably cytokines will be decreasing amount and you will get lesser inflammation uh so there are various type of jack enzymes subject 1 j2 j3 tyrosine kinase 2 but out of this jack one acts only on colonic epithelia not even on small bowel epithelium so uh first object inhibitor is now available in india for last couple of years and that is what we call topha or tofacitini it's a it's a non-specific inhibitor first of the line of drugs that are going to come and more specific drugs will keep coming so they inhibit activity of interleukin 2 4 15 20 where one and what have you various that kind of inhibitors but in short for a practitioner they dampen down the hyperinflation which keeps uncertainty varieties going on and on and on and we had fortune to use capacity and in some patients it worked so probably after sales of irene and five aminosilic acid probably if your patient is still getting a problem with colitis it's not coming under control you may consider using profacity name nobody knows where exactly to put it but if you want to spare patients the myriad of side effects of steroid steward will also encourage in infections and jack inhibitors also does do that but it doesn't produce diabetes it doesn't produce bone thinning or acidity or hypertension whatever so probably after cellulose of pyridine fibromyalic acid either oral or oral or corrector you may consider to facita if your experience holds out like what we have seen in trials uh or after steroids if you have to use repeated scenarios you can use trophoceneum it's an oral drug uh and uh works within first three days but like all uh these steroids and everything it encourages infections so you have to screen the patient for tuberculosis or upper aesthetic infections or something else vaccinate as much as you can and then you can start your drag individuals and obviously later uh drugs like infliximab and all the rest of it now jake one panzer inhibitorist of acetonin and specific inhibitor of gluteny and both are in one stage of trial and hopefully they will be available for use in near future only there's a phase three trial and soon they are going to be approved for general use so these are about jack inhibitors and their function is to dampen down the hyperinflation or enthusiastic response or one can say over enthusiastic response of this resident security agents macrophages and dendritic cells and i would use it if we have to use steroid repeatedly or when you think you need to require steroids you may try this to facetime also but time will tell where exactly to put dophacet in or when comes figuratini and upper acetylene and they will be preferred if they work just like tofas because they are specific to cola okay this is about to facility name and main risk is a parasitic infection common core or disorder hyperlipidemia etcetera so you take care of this or and watch out for these infections next is uh tnf alpha is also produced by dendritic cells and macrophages and we have got wonderful drug uh in fxmap and aluminum both are tnf alpha antagonists the only difference is tophas navy prevents the production of these cytokines and inflix mm and aluminum web will antagonize this this cytokines especially tnf alpha once they are produced and in crohn's disease infliction can work miracles believe me i've seen patients and i i lost sleep how this patient will get better what is the quality of their life six months down the road after inflexible when they come everything is good the results are not as dramatic in ulcerative colitis but nevertheless both drugs are working and if you are struggling with the repeated course of steroid and if your trauma certainly is not working both in fxmf or adelma are worth trying uh okay now uh dendritic cells will activate t cells and various intelligence will be produced these interleukins will inform spleen and lymph nodes and all the rest of it that i may need more help so this signal is conveyed to lymph nodes and if the signal is correctly interpreted more white cells will be released but in colitis this is as we discussed this hyper response so australia available in western countries is another drug that is available and will be available hopefully soon in this country if already not available in certain centers what user kind of does is it prevents the signal to reach to lymph nodes so lymph nodes don't know what is happening they don't know whether to send more troops to help and everything will be well controlled so osteokynape is another important drug a few words about mr kyanite and they control il-23 il-22 and they used to kind of prevent recruitment of more lymphocytes more white cells into colonic lamina propria so if you control this hyperinflammation will be controlled also so this is a new drug and it's it has worked in some patients of colitis hopefully we'll get it also here next the signal goes to lymph nodes spleen and what have you that i need more help of course this is a false signal exaggerated response but nevertheless lymph nodes will send more white cells to the target area now there is a channel which opens up and through this this white cells will go out what if we block this channel then they won't although their lymph nodes will receive signals lymphocytes white cells will not come out because that channel is not activated there is no transport or no door to let them go out the site of fight so what is that ozini mode is the drug which will prevent egress of white cells from lymph node to the site of inflammation ozino mode is recently approved is a sphingosine one receptor antibodies but we are not bothered with that we are bothered to know that it will work in certain cases so they are responsible for controlling the aggressive lymphocytes from lymphoid organs and ozone mode is recently approved for moderate to severe certain colitis it's an overall drug and hopefully we will get it in our country in short time in a couple of years we'll get ozino mod so we'll have one more drug to fight ulcerative colitis okay uh is well rotated and most commonly reported adverse events are abnormal liver tests in about five percent of patient and headache so monitor your electrician monitor obviously for any other infections because trials have limited population but when using general population you have side effects which you never detected in trials but when it comes it will be a good drug to use in ulcerative colitis lastly when these white cells are coming out into circulation they home into the defected lease area defective area or inflamed area and they using a receptor they get out of the vascular endothelium into the lamina propria and start fighting and in case of severe certifications they do more damage which was already there but they they reach there and start more fights and there will be more ulcerations so vidalism will prevent egress of these cells from blood vessels into lamina propria vitalism or known as widow uh is available in western countries and it is very good in some cases of ulcerative colitis not responding to conventional therapy so friends there are these are the drugs now there are many other interleukins and cytokines and all are produced and one by one they the important one will be found out and will be targeted and the hopeless looking situation in uncertain colitis will improve this is about widow and entral is lisu map but enteralism has a certain cns side effects so it is not researched any further but widow is in the practice in western countries and reportedly gives good results then what about the future now tumor necrosis factor antagonists are given intravenously they are very expensive so people are trying to find out ways to give oral dnf alpha and antagonist or combine oral dnaf alpha and interleukin 23 inhibitors just like hepatitis c treatment combination drug and the virus is gone so if you can find oral tnf alpha and interleukin-23 it will act at different places and the signaling pathway will be blocked then interlock in six centimeters good one we use some in corona virus epidemic you all know that and you have to be very careful with this drug then a human interleukin 25 absolution proteins phosphodiesters for inhibitors they are all being researched and i'm sure in due course we will have them in in our routine use and a cocktail will be found found out which will act at various places in the signaling pathway and that's how it will control ulcerative colitis last word before i go some ayurvedic drugs people in our country you cannot uh stop this trend i mean it's not bad also uh in ayurveda they believe for bilipatra fruit of billah you know the greenish white-ish bold titanium is for microstructure now it is very widely used for gyrus is widely used and villa is a is a dietary substance also so many times patients ask that they can they take villa robilla or village or village tablet or village and i see no reason to stop them um many people change their diet dramatically and i know some very sensible people who have just lived on haldi dhania or namak uh they they died as nothing else and you endoscope them due to the colonoscopy and the colitis is gone pseudopolis has gone and it happens so repeatedly that we may have to say that look you watch your diet and be simple as simple as in your diet and probably the comments are stronger or the antigens which are leaking into the lamina propria uh may not be there or alumina epithelial cells will become very tight and won't allow these antigens or food substances to go into laminar property and start politis so these are practical observations and you may have come across such incidences also so friends this is the exciting stage for ulcerative colitis just like hepatitis b and c where some five or ten years ago and now no longer b or c patient go to transplant in five years i've seen very rare patients of b or c virus going to liver transplant it's all alcoholic liver disease and fatty liver disease with diabetes so hopefully we'll be able to use this many drugs in a combination and control colitis more predictably with reduced morbidity and reduce mortality i thank you all for being present with me and i'll take any suggestions your views or your comments or your questions thank you so much sir uh it was indeed a very informative session and the way like you talked about there are different types of colitis and then their relevance to the treatment as well as the major plays in pathogenesis and how the jack inhibitors act by controlling the immune dysregulation also the new uh research which is going on about the anti-leukocyte trafficking agents so i'm sure as we go ahead like you said and it is going to make the patients and doctors life much better so i think yeah yeah so i'll just uh go with the questions uh dr tj snike is asking what are the modern indications for surgery conservative or ablative total colectomy in my own lifetime i and i i i said me and dr tejas are classmates from say 1970 uh so it is long time i think we are really very senior and we have seen that dramatic decrease in in patients going to surgery he can he's a surgeon and he will immediately say that because you have taken over colitis you will not refer patient to surgery and to some extent it's true also that physician keep going on and on but honestly i've seen some patients who were in very bad shape and with some drug homeopathy or diet or what have you i don't know what so my guess is if you can persevere with medications and give reasonable quality of life uh you may differ surgery uh till such time uh there is no option or there is some complication like perforation or malignancy or dysplasia or something because once colon is removed you can't put it back so i think indications are decreasing uh like for gi bleed now when we were medical students roughly every day we had seven eight ten gj weeds gastroenterology now in a big hospitals civil hospital millions of patients you hardly see this being done so i hope that if if the organ is preserved then probably newer drugs will give them a chance to have a normal column so indications are decreasing but perforation dysplasia or frank malignancy obviously are hardcore indications which will not go away with medical treatment okay dr ramashankar singh is asking so what is the role of diosphene has paradigm i'm not aware of it so honestly okay um we can move on to the next question uh dr kumar is asking that whether like whenever a patient like he has seen that herpes zoster can be caused if acetone is used yes i mean these are all basically like steroid you know if you use steroid bound to decrease the immunity and immediately everyone knows now even a porter knows what his immunity is so obviously they will reduce the immunity because you are especially to first name it's a palm jack inhibitor so it will suppress these resident policemen everywhere so you will get various infections but once we have jack one specific figurative number paracetamol if they work probably we may not see so many cases of disaster so it's question of time only uh when we will have selective jpong inhibitors they are already in phase three drives okay uh on the same line dr sanjeev has asked that whether then anti-herpes zoster vaccine or a chicken box vaccine should be given before giving tofa i i think yes it's a good idea but the impact is what happens that if you say you need to take the next thing is thai food and disaster and what to do there you have to have chest x-ray or ct scan and then patients run away so yes it's a good idea i will not say no it's not it should not be done but in practice if you say so many things thing is the patient will disappear so these are our limitations unfortunately as it is and we almost few patients when we start explaining so we have to balance it accordingly unfortunately but we have got one cyclovir and a cycle will be not good drugs hopefully you choose the middle pathway where you don't lose the patient patient doesn't get severe exhausted and they still you can use to facilitate whatever is coming next all right uh there's okay there was a raise and but it was not there anymore uh dr nisarg is asking what would be the common diet advised and beneficial foods for a patient of ulcerative colitis diet i mean various patients have various contradicting diet for example many doctors say don't drink milk but i don't see the reason why one should not drink milk and if you go to naturopathy and many patients go and we have to listen to them and they are kept on two liters of goat milk it's loaded with milk at one end and in one hand you say stop milk and those patients also get better whatever is the reason so my eyes are open i can't explain it but my eyes are open and if somebody is taking this i will say okay if you benefit take it it's it's after all an established kind line of uh treatment in certain paths so these are contradicting that but spicy still is which will affect any normal person if you eat very spicy fight very spicy food by two three four hours my stomach will hurt so i would say common sense prevails that don't you use this type of exotic diet or spicy or very very sour or oily diet is common sense then milk if you believe in it obviously you stop milk uh and i've seen many patients who have stayed on the near and the colitis is gone so there is something there by chance it could be but the if it is chance it's more than statistically explained kind of chance so yes if you if your patient is agreeable to this i don't see any harm in doing it and there's only one thing that will happen is you will get improved benefit from this diet okay so on the similar lines would you say like dr jitendra is asking so is gluten-free diet helpful gluten is a definite disease but these days you know people there is gluten sensitivity cilia which we see very often but there is non-gluten sensitivity also but if you look at very poorly or djokovic or nadal or what have you they all stopped eating gluten but they don't have gluten sensitivity uh some patients don't have proven sensitivity but they feel better so we call it non-rotating sensitivity but others they they don't have any of this but they still feel better so if these are experimental i i think we can't be very um rigid about it if patient wants to try it yes but ask them to give you feedback so you can pass this on to next patient and i i think i i we are learning all the time and if somebody says something i'll keep that in mind and he got better i have seen myself with endoscopic so why not pass on this knowledge and said that you give me the feedback so i can pass into negation definitely so gluten free yes if you want to try it no harm as it is people don't have anything and they stop beauty so why not train politeness also and give us feedback that's all important ultimately we are here to improve the quality of life our patients and whatever sensible suggestion i don't say okay it's dangerous but these are very sensible suggestions and i will accept them and if it works we'll pass on to the next patient all right asking is there any rule of antidepressants and the anxiety anybody would be depressed and personally i i i think the antidepressants are not the solution the problem the patient is unhappy for whatever reason for colitis or for marital problem or ukraine interesting war or crunching stock market here the antidepressant is not my cup of tea there is a saying that when you are 30 you use 30 drug for one in indication and when you are 60 use one drug for 60 indications [Laughter] so i mean people are fond of using various cocktail of drugs that means probably i think you you are not sure what you're doing and you are you are happy with the numbers so my take is uh these are i mean it's not treating the problem which is his anxiety yeah i can't live normal life i can't go out i mean urgency is so bad in some patients they have to look the door they don't go out in the first place but if they do go if us find [Music] use like we have seen in corona i mean so many bogus drugs been used the bills came in in lakes true so i feel the cause won't be cured by antidepressant but the collateral damage would be definitely financial and you have if you are elderly you will have retention of bearing reflux and both intro dr kumar you can ask your question uh sir it was a very good uh session that we had sir thank you very much and uh coming to the part that uh what are the checklist before uh using the biological sir as we can know from you checklist as we discuss everything is a checklist like uh tuberculosis is number one then your typhoon or apparatus infections or other than tuberculosis will be another one epithet is b hepatitis c listed endless but in our country tuberculosis may be hepatitis b two will be definite checklist you have to make sure that they don't have this and is there anything called uh i mean any phase trials which are still pending like uh like anti sm87 and uh any phases are passed and uh how many trials are going on so many trials are going on we don't know which will come and which will fade away but it's the question of two three four five years before just like hepatitis c seven eight years ago we thought it's a lost cause crohn's disease we thought it's a low score but in fixing we have came in because this is out of question uh wonderful resource uh vaporization is gone so many drugs i don't know which will come and which will fade away but a lot of drugs are being tried a lot of those are uh regarding this vaccination sir should the live vaccines not be given as uh varicella herpes duster and live inhaled influenza and measles are live vaccines that generally they should not be administered uh while on biological therapy sir no no it's not while it is just before uh in counseling and all the rest of it uh and this should be done in technical sense yes we should so do some balancing i'm not saying what i'm saying is right but this is practical problem faced by ordinary physicians like me that if i say [Music] get on with your life i think thank you sir thank you welcome thank you so much dr kumar professor this question was in cholectomy patient is there any effect on the appetite of the patient cholectomy in our experience they they never go i mean very pleasant experience they have some problems so not necessarily they have because but they do have minor problems anyway so yeah if you associate it with this one can save them it's one way or other way related to collect them uh we have two questions about uh if you could uh talk about the differential diagnosis of ulcerative colitis okay and doctor differential diagnosis one is in in this country i may be collided i mean no patients with problems that's our practice the first time when we see that this patient looks like a a phenotype or appearance of ulcerative colitis we make sure that we give them a 10 days 35 milligram per kg dose of may mimic uh just like uncertainty collide so that is mandatory in this country i think no patient with first time diagnose politics should go without this and then you have cytomegalocolitis uh again that is not uncommon especially renal transplant at all so many times when you want to give steroids and all or these inhibitors of biologicals then you look for cytomegalo also then make sure that the patient is not having prostate difficulty or campylobacter or even malignancy sometimes malignant say here who perceive blood are a bleeding pr pisces i've seen so many patients operating for piles because of bleeding pr when they actually have colitis so this can logically fit into a differential diagnosis and then cross colitis which is which can be taken as ulcerative colitis in large bowel and chronos in small bowel in simple term because you can't sometimes differentiate crohn's colitis and ulcerative colitis so these are the common mistakes that people have our practices if you see breeding pr at least do rectoscopy take your colonoscope even if you don't charge it doesn't matter just look up and say look for the first 10 15 centimeters make sure that you are not missing malignancy or certificates or srus solution also syndrome which won't give a breeding pr uh so in long term that that money which you didn't run by doing that will be repaid many times over all right i hope dr yaksha and dr ramashankar sir answered your question dr satish kumar is asking in colonectomy patient is it okay to take normal amount of food or they should take small amounts of food at different times i think you can take normal amount of food so long as you don't have gastrocolic reflex in ulcerative colitis one big problem is super gastroconic reflex the moment you eat you want to pass motion so much so that peace patients are afraid of eating and they lose a lot of weight so if you don't have any of this take normal amount of food uh after all coron's main job is to absorb water and three or four diarrhea if you are doing pouch are bound to happen so they can eat normal food as far as i'm concerned okay um i think those were the questions dr nisarg is asking if there's any one of your like go to prescription that it's the most commonly prescribed drug if it's there any and the dose of it if you have depending upon severe identities if you have mild portrait colitis if your patient is not affording cell as a pilot is still a good drug and we don't see many side effects with sulphur so that is the cheapest or a refined version will be phi amino cellic acid if it is only properties maybe per rectum only if it is more than that you may give morally also these are the go to prescription in most of the patients if they are minor motor collectors obviously things are about to change that's what appears to me uh yes those were the questions so i would like to thank you thank you for such a nice amazing session uh you've actually cleared quite a lot of doubts there are many positive comments in the comments section that it was very informative they have learnt a lot from this so i uh there's one more just one last question was there how can we differentiate non-specific colitis versus ulcerative colitis dr mahesh sometimes it's very difficult and especially biopsy so you have to look at it and many times the first episode my tendency is never to label that you have uncertainty colitis because you have maybe politics or non-specific paradigms or whatever so if it happens repeatedly then you can say look i am not diagnosing you as a circulating one size stamp it like ibs once you step it stamp it nobody will think twice honestly this is a day-to-day problem that patient may have lactose intolerance or celiac disease or many things or metformin-induced diarrhea or vaguely bose or a carbon's induced diary and you say so this these labels i i don't like uh unless i have done as much work as possible and similarly in colitis many times it's very difficult to say whether it's going to reveal as uncertain politics in due course of time but we say that look you have positive politics but we will see after three months six months and if everything is fine probably don't bother or label patient with ulcerative colitis even though is in remission so if patients go to doctor google and they always say you will develop cancer you will have to have colonoscopy every day so they get very depressed so we will this will require a lot of counselling especially chronic disease that you have a problem this could be also correct but i am not labeling it right now because this is first episode it could be any number of agents which i have tested which i have not tested but if you have repeated and you just come negative then obviously this will be uncertain but biopsy never because if you have one tiny ulcer get on to see only that sample and you will say kryptitis and crypt says and what have you because he has nothing not seen anything more than a half a millimeter sample and you have opportunity to see the whole color uh the story the joint pain the back pain your the anemia the gastrocorrect reflect then you can say hey look there was one simple sorry yeah absolutely like it happened so yes one has to be careful and once uh biopsy especially be careful because there is no diagnostic picture i suggest you only like crohn's disease there is no diagnostic feature yeah yeah if you may have been hyper you have tb but in here they can give you they can mislead you so you have to be your own judge right yes so like i was saying uh it was a very informative session and we have many positive we have emojis coming up we have comments coming up so thank you so much sir

BEING ATTENDED BY

Dr. Murtuza Zozwala & 1093 others

SPEAKERS

dr. Manoj Ghoda

Dr. Manoj Ghoda

Consultant Gastroenterologist | Senior gastroenterologist to Gujarat Research and Medical Institute and Rajasthan hospitals, Ahmedabad, since 1992

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dr. Manoj Ghoda

Dr. Manoj Ghoda

Consultant Gastroenterologist | Senior gastro...

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