What are the management options for emergency room (ER) colitis?

Management of Colitis in the Emergency Room Setting

Emergency room management of colitis requires a multidisciplinary approach with immediate intervention for severe cases and careful medical management for stable patients. 1

Initial Assessment and Triage

• Hemodynamically unstable patients with signs of shock, perforation, or massive bleeding require immediate surgical consultation and intervention 1
• Hemodynamically stable patients should be evaluated through a multidisciplinary approach involving emergency physicians and gastroenterologists 1
• Diagnostic workup should include assessment for acute severe ulcerative colitis using Truelove and Witts criteria: bloody stool frequency ≥6/day plus at least one of tachycardia (>90bpm), temperature >37.8°C, anemia (hemoglobin <10.5g/dL), or elevated ESR (>30mm/h) 1

Medical Management Options

For Acute Severe Ulcerative Colitis

• First-line treatment: Intravenous corticosteroids 2
• If no improvement within 48-72 hours, consider second-line therapy or surgical consultation 1
• Second-line rescue therapies:
  • Intravenous cyclosporine (2 mg/kg) or infliximab (5 mg/kg) for steroid-refractory cases 2
  • Infliximab may be preferred for patients already on immunosuppressives 2
  • Cyclosporine offers rapid onset of action for patients at imminent risk of colectomy 2

For Infectious Colitis

• Antibiotics are not routinely administered for IBD patients unless there is evidence of:
  • Superinfection
  • Intra-abdominal abscesses
  • Sepsis 1
• When indicated, antibiotics should be administered according to local epidemiology and resistance patterns 1
• For bacterial colitis (e.g., Campylobacter, Salmonella, Shigella), antibiotics should be used for high-risk patients and those with complicated disease 3
• Consider testing for Clostridioides difficile in patients with recent antibiotic exposure 4

Supportive Care

• Venous thromboembolism prophylaxis with LMWH should be administered as soon as possible due to high risk in IBD patients 1
• Nutritional support (parenteral or enteral) should be provided according to GI function, in consultation with dietician/nutrition team 1
• Hydration therapy (oral if tolerated, or IV for severe cases) 4

Surgical Management Options

Indications for Emergency Surgery

• Free perforation of the colon 1
• Life-threatening hemorrhage with persistent hemodynamic instability 1
• Generalized peritonitis 1
• Toxic megacolon with signs of clinical deterioration or no improvement after 24-48 hours of medical treatment 1
• Failure to respond to medical therapy after 48-72 hours, including second-line treatments 1

Surgical Procedures

• Subtotal colectomy with ileostomy is the procedure of choice for acute severe ulcerative colitis with massive hemorrhage or non-response to medical treatment 1
• For localized bleeding in Crohn's disease, intraoperative ileoscopy may help identify the bleeding source 1

Diagnostic Procedures for GI Bleeding

• Pre-operative localization of bleeding site is important to exclude upper GI or anorectal bleeding 1
• For stable patients with acute GI bleeding, upper and lower GI endoscopy should be the initial diagnostic procedures 1
• For ongoing bleeding in hemodynamically stable patients after resuscitation, computed tomography angiography should be performed 1

Special Considerations

• Medication management: Consider weaning off steroids (ideally 4 weeks preoperatively unless emergency) and stopping immunomodulators associated with anti-TNF-α agents before surgery to reduce postoperative complications 1
• Antifungals should be reserved for high-risk patients such as those with bowel perforation and recent steroid treatment 1
• For patients with severe ulcerative colitis without toxicity who continue to have symptoms after 7 days of IV steroids, a trial of broad-spectrum antibiotics may be beneficial before considering surgical intervention 5

Common Pitfalls and Caveats

• Delaying surgical intervention in critically ill patients with toxic megacolon can lead to increased morbidity and mortality 1
• Prolonged exposure to steroids increases the risk of perioperative complications 2
• The decision between cyclosporine and infliximab as rescue therapy should consider patient-specific factors, as both may only postpone colectomy in at least half of patients 2
• Post-infectious complications including irritable bowel syndrome and lactose intolerance should be considered in follow-up care 4