Due to the risk of inducing hyperchloraemic acidosis in routine practice, when crystalloid resuscitation or replacement is indicated, balanced salt solutions, eg Ringer' s lactate/acetate or Hartmann' s solution should replace 0.9% saline, except in cases of hypochloraemia, eg from vomiting or gastric drainage. Evidence level 1b * Recommendation 2Solutions such as 4% dextrose/0.18% saline and 5% dextrose are important sources of free water for maintenance, but should be used with caution as excessive amounts may cause dangerous hyponatraemia, especially in children and the elderly. These solutions are not appropriate for resuscitation or replacement therapy except in conditions of significant free water deficit, eg diabetes insipidus. Evidence level 1b * Recommendation 3To meet maintenance requirements, adult patients should receive sodium 50-100 mmol/day, and potassium 40-80 mmol/day in 1.5-2.5 litres of water by the oral, enteral or parenteral route (or a combination of routes). Additional amounts should only be given to correct deficit or continuing losses. Careful monitoring should be undertaken using clinical examination, fluid balance charts, and regular weighing when possible. Evidence level 5 * Preoperative fluid management Recommendation 4In patients without disorders of gastric emptying undergoing elective surgery, clear non-particulate oral fluids should not be withheld for more than two hours prior to the induction of anaesthesia. Evidence level 1a * Recommendation 5In the absence of disorders of gastric emptying or diabetes, preoperative administration of carbohydrate-rich beverages 2-3 h before induction of anaesthesia may improve patient well being and facilitate recovery from surgery. It should be considered in the routine preoperative preparation for elective surgery. Evidence level 2a * Recommendation 6Routine use of preoperative mechanical bowel preparation is not beneficial and may complicate intra-and post-operative management of fluid and electrolyte balance. Its use should therefore be avoided whenever possible. Evidence level 1a* Recommendation 7Where mechanical bowel preparation is used, fluid and electrolyte derangements commonly occur and should be corrected by simultaneous intravenous fluid therapy with Hartmann' s or Ringer-lactate/acetate type solutions. Evidence level 5 * Recommendation 8Excessive losses from gastric aspiration/vomiting should be treated preoperatively with an appropriate crystalloid solution which includes an appropriate potassium supplement. Hypochloraemia is an indication for the use of 0.9% saline,

Forty mg has been shown to be the optimal daily dosage of prednisone for outpatients requiring oral steroids for active proctocolitis. Although daily doses of oral steroids are commonly divided, a single dose each morning causes less adrenal suppression and is more convenient to take. A randomized controlled trial has been performed on patients with proctocolitis, in which 23 received 40 mg prednisolone each morning as one dose, and 22 received 10 mg four times a day, over two weeks. Physicians unaware of the dosage schedule scored the disease activity and assessed the steroid side-effects when the patient entered the trial, at day 7 and at day 14. Of those taking the divided dose the disease improved in 17 and failed to improve in five. No side-effects were observed in ten patients. Of those receiving a once daily regimen, 17 improved and six did not. Nine patients had no side-effects. Further assessment showed no difference between the two groups either in response rate or side-effects produced. When oral steroids are indicated for active proctocolitis, 40 mg prednisolone, as a single dose each morning can be recommended.

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It has been widely assumed that the activity of ulcerative colitis is related to differences in mucosal appearances seen at sigmoidoscopic examination. We have tested this assumption by making comparisons of the symptoms and clinical signs associated with three reproducible appearances of the rectal mucosa. By cross-tabulating 222 observations of each of 10 symptoms and signs with these sigmoidoscopic appearances it has been shown that the subdivision of hemorrhagic mucosae into those which bleed spontaneously and those which bleed only on light touching or scraping is meaningful clinically. Sigmoidoscopic appearances seemed to correlate better with clinical disease activity than histological assessment, even when quantitative, of mucosal biopsies. On the basis of this study, four variables have been suggested which, in addition to the sigmoidoscopic appearances, could form the basis of regular clinical assessment or scoring.

SUMMARY In a prospective, randomised clinical trial, 47 patients with severe, acute, noninfective colitis treated with 60 mg intravenous prednisolone daily, received either bowel rest with parenteral nutrition or oral diet. Although those who received 'bowel rest' experienced a reduction in daily stool weight, there were no differences in the operation or mortality rates between the groups. Fourteen of the 27 patients with ulcerative colitis, but none of the 16 patients with Crohn's disease required urgent surgery. Bowel rest did not affect the outcome in severe ulcerative colitis treated with intravenous prednisolone. Ulcerative colitis and Crohn's colitis behaved differently in the acute attack.Severe attacks of colitis are uncommon but potentially dangerous, particularly if urgent surgical treatment is needed.' 2 Medical treatment of severe colitis relies upon intravenous corticosteroids and nutritional replacement. There has been considerable interest in the use of parenteral nutrition as a possible treatment to reduce mucosal inflammation. The concept of 'bowel rest' is theoretically attractive and one might expect that inflamed intestine would heal more quickly if relieved of mechanical trauma, intestinal secretions, and the antigenic challenge of food. The only controlled trial so far published was not encouraging3 and the present trial was designed to study further the effect of 'bowel rest' in patients with severe attacks of non-infective colitis. Methods PATIENTSA diagnosis of non-specific colitis was established by endoscopy and/or barium enema, in the absence of specific infection or possibility of antibiotic associated colitis.Patients were admitted to the trial if they presented with an attack of colitis severe enough to necessitate admission to hospital and to require treatment with intravenous prednisolone. They were excluded from entry if, at the time of presentation, they exhibited Addrcss for corrcspondcncc: Professor J E Lennard-Jones. St Mark's Hospital, London ECI V 2PS.

Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem. The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness. Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible. There is a lack of data supporting specific nutrients in these conditions. Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period. In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.

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