Should a patient with colitis and a contained perforation be admitted to a hospital medicine service or a surgery service?

From the Guidelines

A patient with colitis and a contained perforation should be admitted to a surgery service rather than a hospital medicine service. This recommendation is based on the potential need for urgent surgical intervention if the patient's condition deteriorates, as highlighted in the guidelines for management of inflammatory bowel disease in the emergency setting 1. While the perforation is currently contained, these situations can rapidly evolve into free perforation with peritonitis, requiring immediate surgical management. The surgical team can closely monitor the patient while initiating conservative treatment, which typically includes bowel rest (NPO status), intravenous fluids, broad-spectrum antibiotics, and pain management.

The importance of urgent surgical consultation in cases of perforation, even when endoscopic repair is technically successful, is emphasized in the AGA clinical practice update on endoscopic management of perforations in the gastrointestinal tract 1. This approach ensures continuity of care and avoids delays in surgical management that might occur with an inter-service transfer if the patient was initially admitted to medicine.

Key considerations in the management of acute severe colitis include the potential for rapid deterioration and the need for a tailored approach that includes close monitoring for signs of progressive deterioration, such as worsening pain or tenderness, progressive leukocytosis, fever, tachycardia, or hypotension 1. The surgical service is better positioned to make rapid decisions about operative intervention if the patient shows signs of clinical deterioration. Additionally, if imaging studies like CT scans show progression of the perforation or development of an abscess, the surgical team can promptly arrange for drainage procedures or definitive surgery.

Some key points to consider in the management of these patients include:

• The potential for rapid progression from contained to free perforation
• The importance of close monitoring for signs of clinical deterioration
• The need for a multidisciplinary approach that includes both surgical and medical specialties
• The potential benefits of early consideration of surgical options or therapeutic alternatives for rescue therapy in cases of steroid-refractory disease.

Overall, admission to a surgery service is recommended for patients with colitis and a contained perforation due to the potential need for urgent surgical intervention and the importance of close monitoring and rapid decision-making in these cases.

From the Research

Admission Decision for Patient with Colitis and Contained Perforation

The decision to admit a patient with colitis and a contained perforation to either a hospital medicine service or a surgery service depends on several factors.

• The patient's condition and the severity of the perforation are crucial in making this decision.
• According to 2, absolute indications for an immediate colectomy include perforation, which suggests that a patient with a contained perforation may require surgical intervention.
• However, the study also notes that medical therapy can be undertaken, and the decision for urgent surgery or non-operative salvage therapy will still be required in 15-50% of patients who fail to respond to standard treatment.

Surgical Intervention

• Studies such as 3 and 4 highlight the importance of urgent surgical treatment for patients with fulminant amoebic colitis or total necrotizing amoebic colitis, respectively.
• In the case of a patient with colitis and a contained perforation, surgical intervention may be necessary to prevent further complications, as seen in 5, where a young female with ulcerative colitis and a contained perforation underwent colectomy and end ileostomy.
• The decision to perform surgery should be made after multidisciplinary discussion, taking into account the patient's overall condition and the potential risks and benefits of surgical intervention.

Hospital Medicine Service vs. Surgery Service

• While there is no direct evidence to suggest that a patient with colitis and a contained perforation should be admitted to a specific service, the studies suggest that surgical intervention may be necessary in some cases.
• Admission to a surgery service may be more appropriate if surgical intervention is likely to be required, as seen in cases of fulminant amoebic colitis or total necrotizing amoebic colitis.
• However, if the patient's condition is stable and medical therapy is being considered, admission to a hospital medicine service may be more suitable, with close monitoring and collaboration with surgical services if necessary, as noted in 2 and 6.