What is the management approach for hemicolitis (inflammation of half of the colon)?

Management of Hemicolitis

The management of hemicolitis requires a multidisciplinary approach involving gastroenterologists and colorectal surgeons, with treatment strategies based on disease severity, pattern, and activity.

Initial Assessment and Diagnosis

• Diagnostic workup:

  • CT with IV contrast is the imaging modality of choice to confirm diagnosis, assess severity and distribution of inflammation 1
  • Lower GI endoscopy within 48 hours (if patient is stable) to evaluate extent and severity of disease 1
  • Stool studies: culture, C. difficile toxin, parasites, viral pathogens 2
  • Laboratory tests: CBC, CRP, ESR, serum electrolytes, albumin, liver function tests 3
  • Daily abdominal radiography if colonic dilatation is present (transverse colon diameter >5.5 cm) 3

• Rule out other causes:

  • Infectious colitis (including C. difficile, E. coli O157:H7) 4, 5
  • Ischemic colitis 1
  • Antibiotic-associated hemorrhagic colitis 6

Management Based on Severity

Mild to Moderate Disease

1. First-line therapy:

   • Oral mesalazine (5-ASA) 2-4g daily combined with topical mesalazine 1g daily 2
   • Higher doses (4g/day) for moderate disease 2

2. If inadequate response:

   • Oral prednisolone 40mg daily with gradual taper over 8 weeks 3, 2
   • Budesonide 9mg daily may be appropriate for isolated ileo-cecal disease 3

Severe Disease

1. Hospital admission with:

   • IV fluid and electrolyte replacement 3
   • IV corticosteroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) 3
   • Subcutaneous heparin for thromboembolism prophylaxis 3
   • Nutritional support (enteral or parenteral) if malnourished 3
   • Blood transfusion to maintain hemoglobin >10 g/dl 3
   • Daily monitoring of vital signs, stool frequency, and laboratory parameters 3, 2

2. If no improvement within 3-5 days:

   • Consider rescue therapy with infliximab or cyclosporine 2
   • Consult with colorectal surgeon for possible surgical intervention 3

Refractory Disease

1. Medical options:

   • Anti-TNF therapy (infliximab, adalimumab, golimumab) 2
   • Vedolizumab or upadacitinib 2
   • Antibiotics may provide benefit in some cases 7

2. Surgical indications:

   • Free perforation 3
   • Life-threatening hemorrhage with hemodynamic instability 3
   • Generalized peritonitis 3
   • Toxic megacolon with clinical deterioration or no improvement after 24-48 hours 3
   • Failure to respond to medical therapy within 48-72 hours 3

Toxic Megacolon Management

• Immediate surgical exploration in hemodynamically unstable patients 3
• If stable, aggressive medical management with:
  • IV steroids 3
  • Broad-spectrum antibiotics 3
  • Close monitoring for signs of deterioration 3
• Surgery is mandatory if no clinical improvement or biological signs of deterioration after 24-48 hours 3
• Subtotal colectomy with ileostomy is the surgical treatment of choice 3

Maintenance Therapy

• Lifelong maintenance therapy is generally recommended 3
• Options include:
  • Oral mesalazine 2-4g daily 2
  • Azathioprine or mercaptopurine for those who cannot maintain remission on 5-ASA 2
  • Continue biologics in patients who responded to induction therapy 2

Important Considerations

• Joint management with a colorectal surgeon is essential, as 25-30% of patients may require colectomy 3
• Avoid delaying surgery in critically ill patients, especially with toxic megacolon 3
• Avoid opioids when possible due to risks of dependence and gut dysmotility 2
• Regular surveillance colonoscopies should be performed to monitor disease and screen for dysplasia/cancer 2

Common Pitfalls to Avoid

• Delaying treatment while awaiting microbiological results 2
• Inadequate dosing of 5-ASA compounds 2
• Prolonged steroid use without appropriate steroid-sparing strategies 2
• Failure to recognize infectious causes of colitis 2
• Not considering a multidisciplinary approach with gastroenterology and surgical consultation for severe disease 2