What is the initial approach to treating colitis in the emergency department (ED)?

Initial Management of Colitis in the Emergency Department

The initial approach to treating colitis in the emergency department requires immediate hemodynamic assessment, with hemodynamically unstable patients needing surgical consultation, while stable patients should undergo multidisciplinary evaluation involving emergency physicians and gastroenterologists. 1

Initial Assessment

• Evaluate hemodynamic stability immediately upon presentation - patients with signs of shock, perforation, or massive bleeding require immediate surgical consultation 1
• Assess for signs of severe disease including:
  • Toxic megacolon (clinical deterioration, signs of shock) 2
  • Free perforation with peritonitis 2
  • Massive colorectal hemorrhage 2
• Perform diagnostic workup using Truelove and Witts criteria for acute severe ulcerative colitis 1

Medical Management for Hemodynamically Stable Patients

• For hemodynamically stable patients with colitis, initiate medical therapy while monitoring for response:

  • Intravenous corticosteroids remain first-line therapy for acute severe colitis 3
  • Administer venous thromboembolism prophylaxis with LMWH as soon as possible due to high risk in IBD patients 1
  • Antibiotics should only be given if there is evidence of superinfection, intra-abdominal abscesses, or sepsis 1
  • For ulcerative colitis, mesalamine may be considered for mild to moderate disease 4

• Monitor for response to initial therapy:

  • If no improvement within 48-72 hours of first-line treatment, consider second-line therapy or surgical consultation 1
  • For non-responders to corticosteroids, rescue therapy options include infliximab or cyclosporine 3

Diagnostic Procedures

• For hemodynamically stable patients with gastrointestinal bleeding:
  • Perform sigmoidoscopy and esophagogastroduodenoscopy as initial diagnostic procedures 2
  • Computed tomography angiography should be performed in patients with ongoing bleeding who are hemodynamically stable after resuscitation 2
• Any colorectal stricture should be assessed with endoscopic biopsies to rule out malignancy 2

Indications for Surgical Management

• Surgery is mandatory in the following scenarios:

  • Perforation, massive bleeding with hemodynamic instability, clinical deterioration and signs of shock 2
  • Toxic megacolon with no clinical improvement and biological signs of deterioration after 24-48 hours of medical treatment 2
  • Life-threatening bleeding with persistent hemodynamic instability 2
  • Acute severe ulcerative colitis non-responsive to medical treatment with massive colorectal hemorrhage 2

• The surgical procedure of choice for acute severe ulcerative colitis with massive hemorrhage or non-response to medical treatment is subtotal colectomy with ileostomy 2

Surgical Approach Based on Clinical Scenario

• For free perforation and generalized peritonitis or toxic megacolon in hemodynamically unstable patients, an open surgical approach is recommended 2
• For hemodynamically stable patients, a laparoscopic approach may reduce length of stay and morbidity 2
• In patients with Crohn's disease presenting with perforation and peritonitis who are hemodynamically stable, a laparoscopic approach with resection, lavage and stoma is suggested 2

Common Pitfalls and Caveats

• Delaying surgical intervention in critically ill patients with toxic megacolon can lead to increased morbidity and mortality 1
• Prolonged steroid exposure before surgery increases perioperative complications 1
• Even with rescue therapies like cyclosporine or infliximab, many patients will ultimately require colectomy 5
• Overreliance on "hopeful expectation" to avoid surgery can worsen outcomes - objective assessment of the likelihood of medical failure is essential 6