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 if the symptoms are mild (Grade ≤ 2), consider anti-diarrheal agents, but if symptoms worsen to grade >2, withhold ICI therapy and consider further testing and treatment. Some key considerations in the management of colitis include:

• Evaluating the patient's vital signs, hydration status, and severity of symptoms
• Ordering laboratory tests including complete blood count, comprehensive metabolic panel, C-reactive protein, and stool studies (including cultures, Clostridioides difficile toxin, and calprotectin)
• Considering empiric antibiotic therapy if infectious colitis is suspected
• Ensuring adequate hydration with IV fluids if the patient is dehydrated or unable to maintain oral intake
• Pain management with acetaminophen is preferred; avoid NSAIDs and opioids if possible
• If inflammatory bowel disease is suspected, gastroenterology consultation should be obtained for consideration of colonoscopy and possible steroid therapy
• Patients with severe colitis, significant bleeding, toxic megacolon, or perforation require surgical consultation It is also important to consider differentials at time of diagnosis and when incomplete response to treatment or flare, including infection, proximal constipation, Crohn's disease, co-existent irritable bowel syndrome, and rectal prolapse/solitary rectal ulcer, as recommended by the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1. However, the most recent and highest quality study, the AGA clinical practice update on diagnosis and management of immune checkpoint inhibitor colitis and hepatitis 1, should be prioritized in guiding the management of this patient.

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)

Pediatric Ulcerative Colitis: • reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy. (1. 4)

The patient has a CT showing colitis, which is consistent with ulcerative colitis. The next step would be to consider treatment with infliximab (IV), as it is indicated for:

• Reducing signs and symptoms
• Inducing and maintaining clinical remission
• Mucosal healing
• Eliminating corticosteroid use

in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy 2.

Key considerations:

• The patient's disease severity and response to conventional therapy should be assessed before initiating treatment with infliximab (IV).
• The patient should be closely monitored for serious infections and malignancies, as these are potential risks associated with TNF blocker therapy 2.

From the Research

Next Steps for Patient with Abdominal Pain and CT Showing Colitis

• The patient's CT scan showing colitis indicates the need for further evaluation and management of ulcerative colitis (UC) 3.
• The diagnosis of UC is typically based on a combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses 3.
• Given the patient's abdominal pain and CT findings, the next steps may include:
  • Ileocolonoscopy with biopsy to confirm the diagnosis of UC and assess the extent and severity of inflammation 3.
  • Evaluation of the patient's disease severity using the Mayo scoring system to guide treatment decisions 3.
  • Initiation of treatment with topical or systemic corticosteroids, depending on the severity of the disease 4, 5.
  • Consideration of other treatment options, such as 5-aminosalicylic acid (5-ASA) drugs, immunomodulators, or biologics, depending on the patient's response to initial treatment 3.

Management of Abdominal Pain in Ulcerative Colitis

• Abdominal pain is a common symptom in patients with UC, and its management should go beyond just treating inflammation 6.
• The patient's pain rating, quality of life, and psychiatric comorbidities should be assessed and addressed as part of their overall management plan 6.
• The use of abdominal CT scans in the management of patients with severe acute colitis complicating inflammatory bowel disease is not helpful in surgical decision making 7.

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 include:
  • Topical 5-ASA drugs for proctitis 3.
  • Combination of oral and topical 5-ASA drugs +/- corticosteroids for more extensive or severe disease 3.
  • Intravenous steroids and other medications, such as calcineurin inhibitors or tumor necrosis factor-α antibodies, for patients with severe UC 3, 4, 5.