Treem W R, Cohen J, Davis P M, Justinich C J, Hyams J S
Division of Pediatric Gastroenterology and Nutrition, Hartford Hospital, Connecticut, USA.
Dis Colon Rectum. 1995 May;38(5):474-9. doi: 10.1007/BF02148846.
Emergency surgery for fulminant colitis is often complicated by high-dose steroid therapy, poor nutrition, and psychologic maladjustment. Cyclosporine is effective for fulminant ulcerative colitis in adults, resulting in avoidance of immediate surgery in 75 percent of patients and a 55 percent long-term remission rate. Over the last five years, we studied the effectiveness of cyclosporine in children with fulminant colitis.
Fourteen patients with ulcerative colitis (age, 7-20 years) received cyclosporine after satisfying the following criteria: 1) greater than five bloody diarrheal stools per day; 2) severe abdominal pain; 3) no improvement after ten days of bowel rest, 4) intravenous methylprednisolone (1-2 mg/kg/day); and 5) parenteral nutrition. Treatment was begun with oral cyclosporine (4.6-9.6 mg/kg/day), and the dose was adjusted to achieve whole blood trough levels measured with a monoclonal radioimmunoassay between 150 and 300 ng/ml. If improved, patients were discharged on oral cyclosporine, prednisone, and a regular diet.
Eleven of 14 patients (78 percent) responded within two to nine days and were able to consume a normal diet, had three or less soft stools per day, and had no pain. One did not respond after ten days and underwent an ileal pouch-anal anastomosis procedure. Two patients elected surgery after 20 days of therapy and a partial response. Of 11 patients who left the hospital, 4 had recurrent symptoms after 2 to 11 months of taking therapeutic doses of cyclosporine and 3 flare ups while weaning from cyclosporine after 4 to 8 months. Three patients have been weaned from cyclosporine after 8 to 13 months and have remained in remission from six months to five years. One patient is about to complete a six-month course of cyclosporine. Overall ten (72 percent) have undergone surgery, including 7 of 11 who responded initially to cyclosporine and left the hospital. Weight (P < 0.001), albumin (P < 0.01), erythrocyte sedimentation rate (P > 0.05), and prednisone dose (P < 0.001) improved significantly in the seven patients on cyclosporine who responded initially, left the hospital, and subsequently underwent surgery.
Cyclosporine is effective in achieving clinical remission in 80 percent of children with refractory fulminant colitis; however, within one year, most initial responders will require colectomy because of a flare up of the disease. In a majority of patients, the role of cyclosporine therapy is to rapidly ameliorate symptoms and prevent precipitous colectomy, improve nutrition and psychologic adaptation, and reduce the steroid dose leading to surgery in a well-prepared patient.
暴发性结肠炎的急诊手术常因大剂量类固醇治疗、营养不良和心理失调而变得复杂。环孢素对成人暴发性溃疡性结肠炎有效，75%的患者可避免立即手术，长期缓解率为55%。在过去五年中，我们研究了环孢素对儿童暴发性结肠炎的疗效。
14例溃疡性结肠炎患儿（年龄7 - 20岁）在满足以下标准后接受环孢素治疗：1）每日血性腹泻大便超过5次；2）严重腹痛；3）肠道休息10天后无改善；4）静脉注射甲泼尼龙（1 - 2mg/kg/天）；5）肠外营养。治疗从口服环孢素（4.6 - 9.6mg/kg/天）开始，调整剂量以使通过单克隆放射免疫测定测得的全血谷浓度在150至300ng/ml之间。如果病情改善，患者出院时服用口服环孢素、泼尼松并恢复正常饮食。
14例患者中有11例（78%）在2至9天内有反应，能够正常饮食，每日软便3次或更少，且无疼痛。1例在10天后无反应，接受了回肠储袋肛管吻合术。2例患者在治疗20天后部分缓解，选择了手术。11例出院患者中，4例在服用治疗剂量环孢素2至11个月后出现复发症状，4至8个月在环孢素减量过程中有3例病情复发。3例患者在8至13个月后停用环孢素，缓解期持续6个月至5年。1例患者即将完成6个月的环孢素疗程。总体而言，10例（72%）患者接受了手术，包括最初对环孢素有反应并出院的11例患者中的7例。最初有反应、出院并随后接受手术的7例接受环孢素治疗的患者，体重（P < 0.001）、白蛋白（P < 0.01）、红细胞沉降率（P > 0.05）和泼尼松剂量（P < 0.001）有显著改善。
环孢素对80%难治性暴发性结肠炎患儿有效，可实现临床缓解；然而，在一年内，大多数最初有反应的患者因疾病复发将需要行结肠切除术。在大多数患者中，环孢素治疗的作用是迅速改善症状，防止仓促行结肠切除术，改善营养和心理适应，并在准备充分的患者中减少导致手术的类固醇剂量。
