Update on Ulcerative Colitis

(Great Britain— The Practitioner, March 2001, p. 224.) Ulcerative colitis is a chronic, relapsing and remitting, superficial inflammatory bowel condition that spreads proximally from the rectum and can present with a spectrum of severity from acute total colitis to isolated colitis or proctitis. The incidence of ulcerative colitis is increasing (currently about 12 per 100,000 in British populations) and although most cases present between 20 and 40 years of age, there is a second smaller peak of incidence between 60 and 80 years of age. The risk is increased 10-fold in first-degree family members. No infections or other etiologic agents have been identified as a cause, but stress, antibiotics and nonsteroidal anti-inflammatory drugs can precipitate the condition. Being a nonsmoker also appears to be a risk factor for ulcerative colitis. In addition to gastrointestinal symptoms, ulcerative colitis is associated with several conditions including sacroiliitis, uveitis, pyoderma gangrenosum, uric acid renal calculi and anemia. Mild to moderate disease may be managed with oral 5-ASA or steroids. Steroids may also be given as enemas. Oral ASA used on a daily basis reduces the annual relapse rate from 70 to 80 percent without treatment to 20 to 30 percent. Patients require monitoring for complications of the disease and its treatment, including the increased risk of bowel cancer.

Preventing Travelers' Diarrhea

(Great Britain— The Practitioner, March 2001, p. 192.) Up to 50 percent of the more than 30 million persons who travel every year to developing countries experience travelers' diarrhea. About 40 percent of cases seen in Great Britain are attributed to forms of enterotoxigenic Escherichia coli, but no pathogens are identified in 22 percent of cases. Salmonella species, protozoa, Aeromonas/Plesiomonas and Campylobacter jejuni each account for 5 percent or less of cases. Infections with C. jejuni are common in travelers returning from Asia, giardiasis is particularly common in those returning from parts of eastern Europe, and Cryptosporidium in visitors to Russia, particularly St. Petersburg. Travelers' diarrhea is best prevented by practicing careful hygiene and avoiding potential sources of infection. Bismuth sulfate is reported to reduce about 65 percent of infections if taken four times daily. Use of prophylactic antibiotics has been controversial because of the generally limited clinical course of travelers' diarrhea and the risk of incurring side effects and increasing antibiotic resistance for relatively limited benefit. A single 500-mg dose of ciprofloxacin is often recommended. Other antibiotics used include trimethoprim-sulfamethoxazole or doxycycline.

Herpes Zoster Ophthalmicus

(Canada— Canadian Family Physician, March 2001, p. 503.) Up to 20 percent of adults experience herpes zoster (shingles). The ophthalmic division of the trigeminal nerve is involved in approximately 10 percent of cases. Patients may experience a mild prodrome of fever, malaise, fatigue and dysthesia, but most present with a unilateral, painful, vesicular dermatitis of the forehead, scalp, eyelids and nose. The skin lesions progress from erythematous papules to vesicles, pustules and, eventually, crusted lesions. If the disorder is diagnosed within the first 72 hours of eruption of the rash, immunocompetent patients should be treated with oral antiviral agents to decrease viral shedding and induce faster resolution of lesions. Use of oral antiviral agents may also prevent ocular complications and reduce the chances of postherpetic neuralgia. Antiviral agents include acyclovir, valacyclovir and famciclovir. Post-herpetic neuralgia can be resistant to treatment, even with analgesics and amitriptyline.

Discontinuing Antidepressants in Pregnancy

(Canada— Canadian Family Physician, March 2001, p. 489.) Because depression is a common, treatable condition in women of reproductive age, it is not uncommon for women to become pregnant while taking antidepressive medications. Most antidepressants have not been shown to be teratogenic, but many women discontinue their medication during pregnancy and a recent study indicated that physicians frequently advise such discontinuation. Sudden discontinuation can precipitate discontinuation symptoms or re-emergence of the primary psychiatric disorder. Symptoms can include somatic disturbances, insomnia and gastrointestinal problems. The re-emergence of the underlying depression tends to be gradual but symptoms may be severe. In one study involving 36 pregnant women who discontinued antidepressive therapy, 11 had suicidal thoughts and four were later hospitalized. Physicians caring for women who become pregnant while taking antidepressive medication need to provide balanced and accurate information about the potential advantages and risks of discontinuing medication.