From the Guidelines
For a patient with ulcerative colitis experiencing bloody diarrhea, with hemoglobin of 10-13 g/dL and receiving IV steroids and fluids, immediate surgical consultation is crucial if signs of bowel perforation or toxic megacolon are present, as mortality rates can reach 40% if not promptly addressed. The most concerning signs of these complications include severe abdominal pain, abdominal distension, fever above 38.5°C, tachycardia, hypotension, and altered mental status 1. Additional warning signs include absent bowel sounds, peritoneal signs (rebound tenderness, guarding), and radiographic findings showing colonic dilation exceeding 6 cm. Laboratory markers suggesting severe disease include leukocytosis, elevated inflammatory markers (CRP, ESR), and electrolyte abnormalities.
According to the most recent guidelines, surgery is mandatory in patients presenting with toxic megacolon complicated by perforation, massive bleeding, clinical deterioration, and signs of shock 1. Furthermore, surgery should not be delayed in critically ill patients presenting with toxic megacolon, as recommended by the WSES-AAST guidelines 1. The initial management of severe active ulcerative colitis involves intravenous steroids, such as methylprednisolone 60 mg every 24 hours or hydrocortisone 100 mg four times daily, and adequate intravenous fluids, as well as low-molecular-weight heparin for thromboprophylaxis and correction of electrolyte abnormalities and anemia if needed 1.
In cases where intravenous corticosteroid fails to induce a clinical response by day 3, rescue therapies such as infliximab, ciclosporin, or surgery should be considered, depending on the judgment of the treating physicians, drug availability, prior thiopurine failure, and patient preference 1. However, the most critical factor in managing these life-threatening complications is early recognition and prompt intervention to prevent increased morbidity and mortality. Therefore, close monitoring with serial abdominal exams, vital signs, and radiographic studies is essential to identify signs of bowel perforation or toxic megacolon early and initiate appropriate management.
From the Research
Patient Profile
- The patient has ulcerative colitis with recurring episodes of bloody diarrhea.
- The patient's hemoglobin level is 10.13 g/dL, which is unremarkable.
- The patient is started on IV steroid and IV fluids.
Treatment Options
- According to 2, patients with severe UC need to be hospitalized for treatment, which includes intravenous steroids and, if refractory, calcineurin inhibitors or tumor necrosis factor-α antibodies.
- As stated in 3, intravenous corticosteroids remain the first-line therapy for acute severe colitis, but many patients do not respond and require escalation to calcineurin inhibitors or infliximab.
- 4 suggests that cyclosporine therapy can be used as a rescue treatment in steroid-refractory acute severe ulcerative colitis, with a clinical response rate of 82.5% on the seventh day.
Complications
- As mentioned in 2, indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding.
- According to 5, up to 15% of cases may require surgical treatment due to medical therapy failure or development of dysplasia secondary to long-standing colitis.
- 6 notes that cyclosporine should be used only to induce remission and serve as a "bridge" to azathioprine or 6-mercaptopurine maintenance therapy, due to the risk of dose-dependent adverse effects.
Bowel Perforation and Toxic Mega Colon
- As stated in 2, bowel perforation and toxic mega colon are indications for emergency surgery in patients with ulcerative colitis.
- According to 3, clinicians must be able to identify patients who will have a worse prognosis and plan aggressive therapy with early/proactive adjustments in management if needed.
- 4 found that patients who underwent colectomy had a higher basal Lichtiger score and lower basal hemoglobin value compared to those who did not undergo colectomy.