What is the initial treatment for acute colitis?

Initial Treatment for Acute Colitis

For acute severe ulcerative colitis, initiate intravenous corticosteroids immediately—either hydrocortisone 100 mg four times daily or methylprednisolone 40-60 mg daily—along with aggressive supportive care including IV fluids, electrolyte replacement (at least 60 mmol/day potassium), and thromboprophylaxis with low-molecular-weight heparin. 1, 2

Immediate Assessment and Stabilization

Diagnostic Workup

• Perform unprepared flexible sigmoidoscopy with biopsies to confirm diagnosis, assess severity, and exclude cytomegalovirus infection 1
• Obtain stool cultures and test for Clostridium difficile toxin, which is more prevalent in severe UC and associated with increased morbidity and mortality 1
• Baseline laboratory tests should include complete blood count, CRP, albumin, urea, electrolytes, and liver function tests 1, 2

Essential Supportive Measures

• IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day to prevent hypokalaemia and toxic dilatation 1, 2
• Subcutaneous low-molecular-weight heparin for thromboprophylaxis—rectal bleeding is NOT a contraindication 1, 2
• Blood transfusion to maintain hemoglobin above 8-10 g/dL 1
• Nutritional support if malnourished—enteral nutrition is preferred over parenteral (9% vs 35% complications) 1
• Withdraw anticholinergic, anti-diarrheal, NSAID, and opioid drugs which may precipitate colonic dilatation 1

First-Line Medical Therapy

Corticosteroid Regimen

Intravenous corticosteroids are the standard initial treatment and should not be delayed pending screening tests 1, 2:

• Hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily 1, 2
• Higher doses provide no additional benefit but increase adverse events 1, 2
• Bolus injection is as effective as continuous infusion 1
• Treatment duration should be limited to 7-10 days maximum—extending beyond this carries no additional benefit 1, 2

Expected Response

• Overall response rate to IV corticosteroids is 67%, with 33% requiring colectomy 1
• Formal assessment of response is required on day 3 to identify patients needing rescue therapy 1, 2

Assessment for Rescue Therapy

Day 3 Criteria (Oxford Criteria)

Failure to respond is defined by 1, 2:

• >8 stools per day OR
• 3-8 stools per day with CRP >45 mg/L
• This predicts 85% colectomy rate without rescue therapy 1

Day 7 Criteria

• >3 stools per day or visible blood indicates 40% colectomy rate in ensuing months 1

Additional Poor Prognostic Indicators

• Mucosal islands or colonic dilatation on plain abdominal X-ray 1
• Deep ulceration on flexible sigmoidoscopy 1

Second-Line Rescue Therapy

If no improvement or deterioration within 48-72 hours, consider rescue therapy or surgery 1:

Rescue Options (Equivalent Efficacy)

• Infliximab 5 mg/kg IV at weeks 0,2, and 6 2, 3
• Ciclosporin 2 mg/kg/day IV 1, 2, 3

Ciclosporin monotherapy (without concomitant IV steroids) is particularly useful for patients who should avoid steroids—those with steroid psychosis, osteoporosis, or poorly controlled diabetes 1

Surgical Indications

Immediate Surgery Required

Emergency colectomy is mandatory for 1:

• Free perforation with generalized peritonitis 1
• Life-threatening hemorrhage with hemodynamic instability 1
• Toxic megacolon with perforation, massive bleeding, or shock 1

Urgent Surgery Indicated

• No improvement with second-line therapy after 4-7 days 1, 2
• Toxic megacolon with no clinical improvement after 24-48 hours of medical treatment 1
• Subtotal colectomy with ileostomy is the surgical treatment of choice 1

Multidisciplinary Management

Joint care by gastroenterologist and colorectal surgeon is essential 1:

• Early surgical consultation prevents delayed surgery and associated high morbidity 1
• Overall mortality of ASUC is 1%, but significantly higher in patients >60 years with comorbidities 2
• 20-29% of ASUC patients require colectomy during the same admission 2

Common Pitfalls to Avoid

• Do NOT routinely use antibiotics unless infection is suspected or immediately prior to surgery—controlled trials show no consistent benefit 1
• Do NOT delay surgery in critically ill patients with toxic megacolon 1
• Do NOT use bowel rest with parenteral nutrition routinely—it does not alter outcomes and has more complications than enteral feeding 1
• Do NOT extend IV corticosteroid therapy beyond 7-10 days—this increases toxicity without benefit 1, 2