What is the treatment approach for transverse colitis?

Treatment of Transverse Colitis

The treatment approach for transverse colitis depends critically on the underlying etiology and disease severity, but for inflammatory bowel disease affecting the transverse colon, combination therapy with oral mesalazine 2-4 g daily plus topical mesalazine 1 g daily represents first-line treatment for mild-to-moderate disease, with corticosteroids reserved for inadequate response. 1, 2

Initial Diagnostic Considerations

Before initiating treatment, you must:

• Exclude infectious causes through stool culture and testing, though corticosteroid therapy should not be delayed while awaiting results if severe disease is suspected 1, 2
• Confirm diagnosis and assess severity via endoscopy with biopsy to document active inflammation and rule out alternative diagnoses (Crohn's disease, ischemic colitis, microscopic colitis, malignancy) 1
• Evaluate for proximal constipation using abdominal X-ray, as abnormal intestinal motility can induce proximal colonic stasis affecting drug delivery; if fecal loading is present, add laxatives 1
• Review medication adherence and treatment history, as poor adherence is a common cause of apparent treatment failure 1, 2

Treatment Algorithm by Disease Severity

Mild-to-Moderate Disease

First-line therapy:

• Oral mesalazine 2-4 g daily combined with topical mesalazine 1 g daily for optimal mucosal drug delivery 2
• Combination therapy is more effective than either agent alone 1

If inadequate response after 2-4 weeks:

• Add oral prednisolone 40 mg daily, tapered gradually over 8 weeks according to clinical response 1, 3
• Continue mesalazine as adjunctive therapy during corticosteroid treatment 3

Severe Disease (Meeting Truelove and Witts' Criteria)

Immediate hospitalization is required with joint gastroenterology-surgery management 1, 2

Inpatient management includes:

• Intravenous hydrocortisone 100 mg four times daily or methylprednisolone 30 mg every 12 hours as first-line treatment 2
• IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day 2
• Subcutaneous heparin for thromboprophylaxis (rectal bleeding is not a contraindication) 1, 2
• Daily monitoring: vital signs four times daily, stool frequency/character, complete blood count, C-reactive protein, electrolytes, albumin 1, 2
• Daily abdominal radiography if transverse colon diameter >5.5 cm to monitor for toxic megacolon 1

Critical timing consideration: Approximately 67% of patients respond to IV corticosteroids within 3-5 days 2, 4

If inadequate response by day 3-5:

• Rescue therapy with infliximab 5 mg/kg IV or cyclosporine 2 mg/kg/day IV should be initiated 2, 4
• Infliximab is favored in patients already on immunosuppressives due to better short-term safety profile and option for maintenance therapy 4
• Cyclosporine offers rapid onset and short half-life, advantageous when colectomy risk is imminent 4

Maximum IV corticosteroid duration: 7-10 days, as prolonged courses increase toxicity without additional benefit 2

Steroid-Dependent or Refractory Disease

For patients requiring repeated corticosteroid courses or unable to taper:

• Thiopurines (azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day) as steroid-sparing agents 1
• Anti-TNF therapy (infliximab, adalimumab, or golimumab), preferably combined with thiopurines for infliximab based on UC-SUCCESS trial showing 39.7% corticosteroid-free remission with combination versus 22.1% with infliximab alone 1
• Vedolizumab as alternative biologic option 1

Maintenance Therapy

Once remission is achieved:

• Lifelong maintenance therapy with aminosalicylates, azathioprine, or mercaptopurine is recommended to reduce relapse risk and potentially decrease colorectal cancer risk 1, 2

Surgical Considerations

Colectomy should be considered when:

• Medical therapy fails after appropriate escalation 1
• Toxic megacolon develops despite medical management 2
• High-grade dysplasia is detected 5

Important prognostic information: Patients should be informed of a 25-30% chance of requiring colectomy with severe disease 1, 3

Common Pitfalls to Avoid

• Do not use anti-diarrheal medications in severe colitis, as they may precipitate toxic megacolon 2
• Do not delay corticosteroids while awaiting stool cultures in severe presentations 1
• Do not continue IV corticosteroids beyond 7-10 days without reassessing for rescue therapy or surgery 2
• Do not miss proximal constipation as a cause of treatment failure in left-sided disease extending to transverse colon 1