What is the initial treatment for iliocolitis in the emergency room (ER)?

Treatment of Iliocolitis in the Emergency Room

For hemodynamically stable patients with iliocolitis in the ER, initiate intravenous corticosteroids (methylprednisolone 60 mg/24h or hydrocortisone 100 mg four times daily) along with IV fluids, electrolyte correction, and thromboprophylaxis with low-molecular-weight heparin, while reserving antibiotics only for documented superinfection or sepsis. 1

Immediate Stabilization and Assessment

Hemodynamic Status Determines Initial Pathway:

• Unstable patients with shock, free perforation, or massive bleeding require immediate surgical consultation and exploration according to damage control principles 1, 2
• Stable patients should undergo multidisciplinary evaluation with gastroenterology to guide medical management 1, 2

First-Line Medical Therapy

Intravenous Corticosteroids:

• Administer methylprednisolone 60 mg every 24 hours OR hydrocortisone 100 mg four times daily 1
• Higher doses provide no additional benefit; lower doses are less effective 1
• Bolus injection is as effective as continuous infusion 1
• Expected response rate is approximately 67% 1

Essential Supportive Measures:

• IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day, as hypokalaemia and hypomagnesaemia can promote toxic dilatation 1
• Thromboprophylaxis with low-molecular-weight heparin administered as soon as possible due to markedly elevated thromboembolism risk during IBD flares 1
• Nutritional support (enteral preferred over parenteral when GI function allows, as enteral nutrition has fewer complications: 9% vs 35%) 1

Diagnostic Workup in the ER

Critical Investigations:

• Unprepared flexible sigmoidoscopy with biopsy to confirm diagnosis and exclude cytomegalovirus infection, which associates with steroid-refractory disease 1
• Stool cultures and Clostridium difficile toxin assay, as C. difficile is more prevalent in severe UC and increases morbidity and mortality 1
• If C. difficile detected, administer oral vancomycin and consider fecal microbial transplant while stopping immunosuppressive therapy if possible 1

Antibiotic Use: A Nuanced Approach

Antibiotics are NOT routinely indicated for IBD patients unless specific complications exist 1. However, the evidence shows divergence:

• Guideline recommendation: Antibiotics should be administered only for documented superinfection, intra-abdominal abscesses, or sepsis, according to local epidemiology and resistance patterns 1
• Research evidence: A small case series suggests severely ill patients without overt toxicity may benefit from broad-spectrum antibiotics after 7 days of failed steroid therapy 3
• Practical approach: Reserve antibiotics for patients with high fever, profound leukocytosis, peritoneal signs, or documented infection 1, 3

Medication Withdrawal:

• Discontinue anticholinergic, anti-diarrhoeal, non-steroidal anti-inflammatory, and opioid drugs 1

Timeline for Escalation

Critical Decision Points:

• Day 3: Consider second-line rescue therapy (ciclosporin, tacrolimus, or infliximab) early to avoid delayed surgery morbidity 1
• 48-72 hours: If no improvement or clinical deterioration occurs, escalate to second-line therapy or surgical consultation 1, 2
• 7-10 days: Do not extend steroid therapy beyond this period, as it carries no additional benefit 1

Alternative First-Line Option

Intravenous Ciclosporin Monotherapy:

• Consider 2-4 mg/kg/day IV ciclosporin as alternative to steroids in patients who should avoid corticosteroids (steroid psychosis susceptibility, severe osteoporosis, poorly controlled diabetes) 1
• Small RCT demonstrated 4 mg/kg/day IV ciclosporin was as effective as IV methylprednisolone 40 mg/day 1

Surgical Indications

Immediate Surgery Required:

• Free perforation of the colon 1, 2
• Life-threatening hemorrhage with persistent hemodynamic instability 1, 2
• Generalized peritonitis 1, 2
• Toxic megacolon with clinical deterioration and signs of shock 1, 2

Urgent Surgery After Failed Medical Therapy:

• No improvement after 48-72 hours of medical treatment 1, 2
• Failure of second-line rescue therapy 1, 2
• Subtotal colectomy with ileostomy is the procedure of choice 1, 4

Common Pitfalls to Avoid

• Delaying surgical consultation in critically ill patients with toxic megacolon increases mortality 2
• Extending ineffective steroid therapy beyond 7-10 days causes high morbidity from delayed surgery 1
• Failing to identify steroid-refractory disease early (by Day 3) delays appropriate rescue therapy 1
• Neglecting thromboprophylaxis despite high thromboembolism risk unrelated to other risk factors 1
• Using antibiotics routinely without documented infection, as they are not indicated for uncomplicated IBD 1