What is the initial treatment for acute colitis in the emergency department (ED)?

Initial Treatment for Acute Colitis in the Emergency Department

The initial treatment for acute colitis in the emergency department consists of intravenous corticosteroids (methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily), along with appropriate intravenous fluid and electrolyte replacement, and thromboprophylaxis with low-molecular-weight heparin. 1, 2

Initial Assessment and Management

1. Diagnostic workup:

   • Stool cultures and assay for Clostridium difficile toxin
   • Unprepared flexible sigmoidoscopy and biopsy (if possible) to confirm diagnosis and exclude cytomegalovirus infection
   • Complete blood count, inflammatory markers (CRP), electrolytes, liver function tests 1, 2

2. Immediate supportive care:

   • IV fluid resuscitation to correct and prevent dehydration
   • Electrolyte replacement, especially potassium (at least 60 mmol/day) as hypokalaemia can promote toxic dilatation
   • Thromboprophylaxis with low-molecular-weight heparin (LMWH) due to high risk of thromboembolism in IBD patients 1
   • Nutritional support if patient is malnourished (enteral nutrition preferred over parenteral) 1

3. Medications to avoid:

   • Anticholinergics
   • Anti-diarrheals
   • Non-steroidal anti-inflammatory drugs
   • Opioids 1

Pharmacological Treatment

First-line therapy:

• IV corticosteroids: Methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily 1, 2
  • Higher doses are not more effective
  • Bolus injection is as effective as continuous infusion
  • Treatment should be given for a defined period (7-10 days maximum)

Alternative first-line therapy:

• IV ciclosporin monotherapy (4 mg/kg/day or 2 mg/kg/day) can be considered for patients who should avoid steroids (e.g., those susceptible to steroid psychosis, osteoporosis, or poorly controlled diabetes) 1

Antibiotics:

• Not routinely administered
• Only indicated if superinfection is suspected or in the presence of intra-abdominal abscess 1
• If C. difficile is detected, oral vancomycin should be administered (125 mg four times daily) 1, 2

Monitoring and Response Assessment

• Assess response to IV steroids by day 3 of treatment 1, 2
• Daily monitoring of:
  • Vital signs
  • Abdominal examination
  • Stool frequency and character
  • Laboratory parameters (CBC, CRP, electrolytes, albumin) 2

Rescue Therapy Considerations

• For patients not responding to IV steroids after 3-5 days, consider rescue therapy:
  • Infliximab in combination with a thiopurine
  • Ciclosporin
  • This decision should be made in a multidisciplinary approach involving gastroenterology 1, 2

Surgical Considerations

• Urgent surgical consultation if:
  • No improvement or deterioration within 48-72 hours of medical therapy
  • Complications such as free perforation, life-threatening hemorrhage, or generalized peritonitis
  • Toxic megacolon with clinical deterioration 1

Common Pitfalls to Avoid

1. Delaying thromboprophylaxis - IBD patients have increased risk of thromboembolism, especially during flares
2. Missing C. difficile infection - Always test for C. difficile in acute colitis
3. Inadequate potassium replacement - Hypokalaemia can worsen colonic dilatation
4. Prolonged ineffective steroid therapy - Assess response by day 3 and consider rescue therapy or surgical options
5. Using antimotility agents - Can precipitate toxic megacolon 1, 2

By following this structured approach, emergency physicians can effectively manage acute colitis while preparing for potential escalation of care if needed.