Treatment of Colitis
Treatment of colitis should be guided by disease type, extent, and severity, with aminosalicylates as first-line therapy for mild to moderate ulcerative colitis, corticosteroids for non-responsive cases, and biologics or immunomodulators for moderate to severe disease. 1
Classification and Initial Assessment
The treatment approach depends on:
- Type of colitis (ulcerative colitis vs. Crohn's disease vs. infectious colitis)
- Disease extent (proctitis, left-sided, or extensive colitis)
- Disease severity (mild, moderate, or severe)
Disease Severity Assessment
- Mild to moderate: <6 bloody stools/day, no systemic toxicity
- Severe: ≥6 bloody stools/day plus at least one of: tachycardia >90 bpm, temperature >37.8°C, hemoglobin <10.5 g/dl, or ESR >30 mm/h (or CRP >30 mg/l) 1
Treatment Algorithm by Disease Extent and Severity
1. Proctitis (Distal Disease)
First-line therapy:
- Topical mesalamine 1g suppository daily combined with oral mesalamine 2-4g daily 1
- Topical mesalamine is more effective than topical steroids 1
For refractory proctitis:
- Add topical corticosteroids
- If no response, oral prednisolone 40mg daily 1
- If still refractory, consider systemic steroids, immunosuppressants, and/or biologics 1
2. Left-Sided or Extensive Colitis
Mild to Moderate Disease:
- Oral mesalamine 4-4.8g daily (start at full dose rather than escalating) 1, 2
- For left-sided disease, add topical mesalamine therapy 1
Moderate to Severe Disease:
Steroid-Dependent Disease:
- Thiopurines (azathioprine) 1
- Anti-TNF therapy (infliximab, adalimumab, golimumab) - preferably combined with thiopurines for infliximab 1
- Vedolizumab 1
- Methotrexate 1
3. Severe Acute Colitis
Requires hospitalization with:
- Daily physical examination
- Monitoring vital signs four times daily
- Stool chart recording
- Regular blood tests (FBC, ESR/CRP, electrolytes, albumin)
- Abdominal radiography if colonic dilatation present 1
Initial treatment:
- IV corticosteroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) 1
- IV fluid and electrolyte replacement
- Blood transfusion to maintain hemoglobin >10 g/dl
- Subcutaneous heparin for thromboprophylaxis
- Nutritional support if malnourished 1
If no improvement within 3 days:
Indications for emergency surgery:
- No improvement after 48-72 hours of medical therapy
- No response to second-line therapy after 4-7 days
- Complications: toxic megacolon, perforation, massive hemorrhage 1, 4
- Subtotal colectomy with ileostomy is the preferred emergency procedure 1
Special Considerations
Infectious Colitis
- Rule out infectious causes with stool cultures and C. difficile testing before initiating immunosuppressive therapy 1, 5
- If C. difficile is detected, treat with oral vancomycin 1
Maintenance Therapy
- Lifelong maintenance therapy is generally recommended, especially for left-sided or extensive disease 1
- Aminosalicylates are first-line maintenance therapy 1
- For those requiring biologics or immunomodulators for induction, these should be continued for maintenance 1
Treatment Monitoring
- Regular assessment of clinical response
- Endoscopic evaluation to confirm mucosal healing
- Monitor for medication side effects
- Adjust therapy if expected improvement goals are not reached 1
Common Pitfalls to Avoid
Delayed surgical consultation in severe colitis - early surgical referral is crucial as colectomy may be life-saving 1, 4
Inadequate initial dosing of aminosalicylates - start with full therapeutic doses (4.8g/day) rather than low doses 2
Prolonged steroid use without steroid-sparing strategies - implement thiopurines or biologics early in steroid-dependent disease 1
Failure to identify alternative explanations for refractory symptoms:
- Poor medication adherence
- Inadequate drug delivery
- Proximal constipation
- Unrecognized infection
- Incorrect diagnosis (IBS, Crohn's disease) 1
Delaying surgery when indicated - prolonged observation in non-responsive severe colitis increases risk of toxic megacolon and perforation 1, 4