What are the next steps for a patient with distal colitis on computed tomography (CT) scan presenting with diarrhea?

From the Guidelines

For a patient with distal colitis identified on CT scan who presents with diarrhea, the next steps should include confirming the diagnosis with colonoscopy and biopsies, as well as stool studies to rule out infectious causes, as recommended by the American Gastroenterological Association 1. The diagnosis of distal colitis requires careful evaluation to determine the underlying cause, which could be inflammatory bowel disease, infectious colitis, or other causes.

• Stool studies should be obtained to rule out infectious causes, including C. difficile toxin, bacterial culture, ova and parasites, and viral pathogens.
• Blood tests including complete blood count, comprehensive metabolic panel, C-reactive protein, and erythrocyte sedimentation rate will help assess inflammation and rule out complications.
• According to the ASCO guideline update, workup of blood and stool should be performed for the initial presentation, and also considered for immunosuppressant refractory cases 1.
• The patient's hydration status should be monitored, and if signs of dehydration are present, intravenous fluids may be necessary.
• Nutritional assessment and support are important as patients with colitis often have nutritional deficiencies.
• The use of antidiarrheal agents like loperamide 2-4mg after each loose stool (maximum 16mg/day) may be considered if there's no concern for infectious colitis, as suggested by the management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: ASCO guideline update 1.
• Once inflammatory bowel disease is confirmed, initial treatment typically includes 5-aminosalicylates such as mesalamine 4.8g daily for mild-moderate disease, with consideration of topical therapy (mesalamine suppositories 1g daily or enemas) for distal disease.
• Endoscopic confirmation of the diagnosis and severity of colitis should be considered before initiation of high-dose systemic glucocorticoids, as recommended by the AGA clinical practice update on diagnosis and management of immune checkpoint inhibitor colitis and hepatitis: expert review 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps for Patient with Distal Colitis

The patient with distal colitis on computed tomography (CT) scan presenting with diarrhea can be managed with the following steps:

• Induction of remission:
  • Topical therapy with 5-aminosalicylic acid (5-ASA) is the treatment of choice in active distal ulcerative colitis 2
  • Oral aminosalicylates, such as mesalazine, can also be effective for both distal and extensive ulcerative colitis 2
  • Corticosteroids, such as rectally administered corticosteroids, can be used to induce remission in patients with mild to moderately active distal ulcerative colitis 3
• Maintenance of remission:
  • Sulfasalazine and mesalazine remain the first-choice drugs for the maintenance therapy of distal ulcerative colitis 3
  • Topical mesalazine (suppositories or enemas) is also effective in maintenance treatment 3
  • Azathioprine and mercaptopurine can be effective in reducing the need for corticosteroids or clinical relapses, and in maintaining long-term remission 3, 4
• Management of refractory disease:
  • Cyclosporin may be useful in inducing remission in patients with acutely severe disease who do not achieve remission with an intensive intravenous regimen 3
  • Azathioprine and mercaptopurine may be effective in prolonging remission in these patients 3
  • Other alternative drugs, such as 5-lipoxygenase inhibitors, topical use of short chain fatty acids, nicotine, local anaesthetics, bismuth subsalicylate enema, sucralfate, clonidine, free radical scavengers, heparin, and hydroxychloroquine, may be considered 3

Treatment Options

The treatment options for distal colitis include:

• 5-ASA therapy: effective in the treatment of mild to moderately active distal ulcerative colitis 3, 4, 2
• Corticosteroids: effective in inducing remission in patients with mild to moderately active distal ulcerative colitis 3, 4
• Azathioprine and mercaptopurine: effective in reducing the need for corticosteroids or clinical relapses, and in maintaining long-term remission 3, 4
• MMX mesalamine: a once-daily oral formulation of mesalamine that can effectively induce and maintain clinical remission in patients with active mild-to-moderate UC 5