What is the treatment for hemorrhagic colitis?

Treatment of Hemorrhagic Colitis

For hemorrhagic colitis, immediate surgical intervention is mandatory in hemodynamically unstable patients presenting with hemorrhagic shock or those who fail to respond to medical treatment. 1

Assessment and Initial Management

Hemodynamic Status Evaluation

• Monitor vital signs four times daily (more frequently if deterioration noted) 1
• Assess for signs of shock or hemodynamic instability
• Record stool characteristics, including presence of blood and frequency 1

Diagnostic Approach

For hemodynamically stable patients:

• Sigmoidoscopy and esophagogastroduodenoscopy should be performed first to evaluate bleeding source 1
• Stool cultures to identify potential pathogens (particularly E. coli O157:H7) 2
• CT angiography for patients with ongoing bleeding who are hemodynamically stable after resuscitation 1
• Laboratory tests: CBC, ESR/CRP, serum electrolytes, liver function tests, and renal function tests every 24-48 hours 1

Treatment Algorithm

For Hemodynamically Unstable Patients:

1. Immediate surgical intervention 1
   • Subtotal colectomy with ileostomy is the surgical treatment of choice for massive colorectal hemorrhage 1
   • Open surgical approach is recommended for unstable patients 1

For Hemodynamically Stable Patients:

1. Supportive Care

   • Intravenous fluid and electrolyte replacement 1
   • Blood transfusion to maintain hemoglobin >10 g/dL 1
   • Subcutaneous heparin to reduce thromboembolism risk 1
   • Nutritional support if malnourished 1

2. Medical Management Based on Etiology

   • For E. coli O157:H7 infection: Supportive care only; antimicrobial therapy has not been shown to shorten illness or prevent complications 2
   • For antibiotic-associated hemorrhagic colitis: Discontinue the offending antibiotic 3
   • For inflammatory bowel disease-related hemorrhagic colitis:
     • Corticosteroids (prednisolone 40 mg daily) for moderate to severe disease 1
     • Consider aminosalicylates for maintenance therapy 1

3. Monitoring for Complications

   • Daily physical examination to evaluate abdominal tenderness 1
   • Daily abdominal radiography if colonic dilatation is present 1
   • Monitor for development of toxic megacolon, hemolytic uremic syndrome, or thrombotic thrombocytopenic purpura 2

4. Indications for Surgical Intervention in Initially Stable Patients:

   • No clinical improvement and biological signs of deterioration after 24-48 hours of medical treatment 1
   • Development of toxic megacolon 1
   • Significant recurrent gastrointestinal bleeding 1
   • Evidence of perforation 1

Special Considerations

Toxic Megacolon

• Do not delay surgery in critically ill patients presenting with toxic megacolon 1
• Surgery is mandatory if complicated by perforation, massive bleeding, clinical deterioration, or signs of shock 1

Clostridium difficile-Associated Hemorrhagic Colitis

• Consider discontinuing antibiotics not directed against C. difficile 4
• Provide appropriate fluid and electrolyte management 4
• Consider surgical evaluation if severe or refractory to medical treatment 4

Pitfalls and Caveats

1. Avoid ciprofloxacin in suspected E. coli O157:H7 hemorrhagic colitis as antibiotics may not improve outcomes and could increase risk of hemolytic uremic syndrome 4, 2

2. Do not delay surgical consultation in patients with severe disease, as early joint medical and surgical management improves outcomes 1

3. Be vigilant for hemolytic uremic syndrome and thrombotic thrombocytopenic purpura, particularly in young children and elderly patients with E. coli O157:H7 infection 2

4. The histologic features of E. coli O157:H7-associated colitis may resemble ischemic colitis, which can lead to misdiagnosis if stool cultures are not obtained 5

5. Antibiotic-associated hemorrhagic colitis typically resolves within three days of discontinuing the offending antibiotic 3