What is the next step in managing a patient with abdominal pain and a computed tomography (CT) scan showing colitis?

From the Guidelines

For a patient with abdominal pain and CT findings of colitis, the next step should be to test to rule out C difficile, CMV, and other alternate etiologies, and consider colonoscopy or flex sigmoidoscopy with biopsies, as recommended by the AGA clinical practice update on diagnosis and management of immune checkpoint inhibitor colitis and hepatitis 1. The patient's clinical symptoms should be graded, and based on the grade, appropriate management should be initiated.

• For grade ≤ 2, consider anti-diarrheal agents, and for symptoms that worsen to grade >2, withhold ICI therapy and consider further testing and treatment.
• The use of stool lactoferrin and calprotectin can help in assessing the severity of colitis.
• Imaging for colitis-related symptoms, such as fever and abdominal pain, should be considered.
• A flexible sigmoidoscopy is often adequate for making a diagnosis, as approximately 95% of patients have inflammation in the left colon on biopsy 1. The management of ICI colitis involves a step-wise approach, including supportive care, consideration of anti-diarrheal agents, and withholding ICI therapy if symptoms worsen.
• For mild symptoms, mesalamine or oral corticosteroids may be considered, while for moderate to severe symptoms, IV corticosteroids, infliximab, or vedolizumab may be necessary 1. It is essential to consider alternate etiologies, including infection, and to consult surgery if necessary.
• The British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults also recommend considering differentials at the time of diagnosis and when there is an incomplete response to treatment or flare 1.

From the FDA Drug Label

Ulcerative Colitis: • reducing signs and symptoms, inducing and maintaining clinical remission and mucosal healing, and eliminating corticosteroid use in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 3)

The patient with abdominal pain and a CT showing colitis may be considered for treatment with infliximab (IV) if they have moderately to severely active ulcerative colitis and have had an inadequate response to conventional therapy. The recommended dose is 5 mg/kg at 0,2 and 6 weeks, then every 8 weeks 2. However, it is essential to assess the patient's overall condition and medical history before initiating treatment with infliximab, considering the potential risks of serious infections and malignancies.

From the Research

Diagnosis and Treatment of Colitis

• The patient's CT scan showing colitis indicates the presence of inflammation in the colon, which could be due to various causes, including ulcerative colitis (UC) or infectious colitis 3, 4.
• To confirm the diagnosis of UC, a combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses is necessary 3.
• Ileocolonoscopy with biopsy is the definitive method for diagnosing UC, and histopathology can assess disease severity and identify potential complications such as dysplasia or cancer 3.

Treatment Options for Ulcerative Colitis

• The goals of treatment in UC are to improve quality of life, achieve steroid-free remission, and minimize the risk of cancer 3.
• Treatment options for UC depend on the extent and severity of the disease, and may include topical or oral 5-aminosalicylic acid (5-ASA) drugs, corticosteroids, or biologic agents such as tumor necrosis factor-α antibodies 3, 5, 6.
• Corticosteroids are effective in inducing remission in mild to moderate UC flares, but are not recommended for long-term maintenance treatment due to potential adverse effects 5, 6.

Management of Abdominal Pain in Colitis

• Abdominal pain is a common symptom in patients with UC, and may be related to inflammation, psychiatric comorbidities, or other factors 7.
• Management strategies for abdominal pain in UC should address both inflammation and psychological mechanisms, and may include interventions such as cognitive-behavioral therapy or other non-pharmacological approaches 7.

Next Steps

• Further evaluation and management of the patient's colitis should be guided by the suspected underlying cause, and may involve additional diagnostic testing, such as stool studies or endoscopy, to confirm the diagnosis and assess disease severity 3, 4.
• Treatment should be tailored to the individual patient's needs, and may involve a combination of medical and supportive therapies to manage symptoms and prevent complications 3, 5, 6.