What is the treatment for colitis in the Emergency Room (ER)?

Emergency Department Treatment of Colitis

For acute severe ulcerative colitis presenting to the ER, initiate intravenous corticosteroids immediately after confirming diagnosis with flexible sigmoidoscopy and ruling out infections, with early surgical consultation and rescue therapy (infliximab or cyclosporine) by day 3 if inadequate response. 1

Initial Assessment and Stabilization

Upon ER presentation, hemodynamically unstable patients require immediate resuscitation with intravenous fluids, correction of electrolyte disturbances (particularly hypokalemia and hypomagnesemia), and blood transfusions if needed. 2 Patients meeting criteria for acute severe colitis—defined as ≥6 bloody stools per day plus at least one systemic sign (tachycardia >90 bpm, fever >37.8°C, hemoglobin <10.5 g/dL, or ESR >30 mm/h)—require hospitalization for intensive management. 1, 2

Critical pitfall: Do not delay surgical consultation. Multidisciplinary coordination between gastroenterology and colorectal surgery must begin on day of admission, as delayed surgery is associated with increased morbidity and mortality. 2

Diagnostic Workup

• Laboratory tests: Complete blood count, C-reactive protein, comprehensive metabolic panel including albumin, liver function tests 2
• Stool studies: Culture and Clostridioides difficile testing to exclude superimposed infections 1, 2
• Imaging: Abdominal X-ray or CT scan to assess for colonic dilatation (>5.5-6 cm indicates toxic megacolon), perforation, or free fluid 2
• Endoscopy: Flexible sigmoidoscopy (not full colonoscopy) to confirm disease activity and obtain histology, while ruling out CMV infection 1

Medical Management Protocol

First-Line Therapy: Intravenous Corticosteroids

Administer hydrocortisone 100 mg IV four times daily or methylprednisolone 30 mg IV every 12 hours immediately after diagnosis confirmation. 2 This achieves a 67% response rate, with 29% ultimately requiring colectomy. 1

Supportive measures to implement concurrently:

• Bowel rest with parenteral nutrition if severe malnutrition present (albumin <3 g/dL, BMI <18.5 kg/m², or >10-15% weight loss) 1
• Thromboprophylaxis with subcutaneous heparin or low-molecular-weight heparin (IBD patients have increased venous thrombosis risk) 2
• Avoid opioids and antidiarrheal agents—these can precipitate toxic megacolon 2

Antibiotics are NOT routinely indicated. Controlled trials of metronidazole, ciprofloxacin, tobramycin, and vancomycin showed no consistent benefit in acute UC. 1 Reserve antibiotics for documented infections or perianal sepsis in Crohn's disease.

Rescue Therapy: Day 3 Assessment

By day 3 of IV corticosteroids, reassess clinical response using stool frequency, abdominal examination, inflammatory markers (CRP), and albumin levels. 1, 2 If inadequate response, escalate to rescue therapy:

Option 1: Infliximab 5 mg/kg IV at weeks 0,2, and 6 1

Option 2: Cyclosporine 2 mg/kg/day IV for 8 days, then 4 mg/kg/day oral 1

The CYSIF trial demonstrated comparable efficacy: 85% response rate by day 7 for both agents, with colectomy rates of 21% (infliximab) vs 18% (cyclosporine) by day 98. 1 Both are equally effective; choice depends on institutional expertise and patient factors.

Surgical Indications

Immediate Surgery Required:

• Toxic megacolon with perforation, massive hemorrhage, or hemodynamic instability 1, 2
• Free perforation with pneumoperitoneum and peritoneal fluid in acutely unwell patients 1
• Hemorrhagic shock unresponsive to resuscitation 1

Surgery Within 24-48 Hours:

• Toxic megacolon without clinical improvement after 24-48 hours of medical treatment 1, 2
• Significant systemic toxicity (severe weight loss, fever, tachycardia, high inflammatory markers, persistent abdominal pain) despite IV corticosteroids 1

Surgical procedure of choice: Subtotal colectomy with end ileostomy. 1 For hemodynamically stable patients, laparoscopic approach may reduce length of stay and morbidity if local expertise exists. 1 For unstable patients with perforation or toxic megacolon, open approach is mandatory. 1

Monitoring Protocol

Daily assessment must include:

• Hemodynamic status and abdominal examination 2
• Stool frequency and character 2
• Serial inflammatory markers (CRP) and albumin 1
• Serial abdominal radiographs if toxic megacolon suspected 2

The mortality rate for acute severe UC is 1% overall, but rises to 27-57% if perforation occurs in toxic megacolon. 2 Approximately 20% of hospitalized patients require colectomy during the same admission. 2

Special Considerations for Crohn's Disease

For Crohn's colitis presenting emergently, the approach differs slightly:

• Enteral nutrition is preferred over parenteral when feasible, reducing postoperative complications from 73.2% to 21.9% 1
• Abscess drainage via interventional radiology before surgery when possible 1
• Perianal sepsis requires drainage, seton placement, and anti-TNF therapy (infliximab or adalimumab); antibiotics (ciprofloxacin plus metronidazole) may be added for short-term benefit 1