What is the management approach for non-infectious colitis?

Management of Non-Infectious Colitis

For non-infectious colitis (ulcerative colitis and Crohn's disease), treatment is stratified by disease severity, extent, and location, with aminosalicylates as first-line therapy for mild-to-moderate disease and escalation to corticosteroids, immunosuppressants, or biologics for refractory or severe cases.

Disease Severity Assessment

Before initiating treatment, classify disease severity using validated criteria 1:

• Severe disease requires hospitalization: bloody stool frequency ≥6/day plus one of the following: tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5 g/dL, or ESR >30 mm/h (or CRP >30 mg/L) 1
• Mild-to-moderate disease can be managed as outpatients 1
• Always exclude infectious causes before escalating therapy, though treatment should not be delayed awaiting stool cultures in severe presentations 1

Treatment Algorithm by Disease Location and Severity

Distal/Proctitis (Disease Limited to Rectum or Up to Sigmoid Junction)

First-line therapy:

• Combination therapy is superior to monotherapy: topical mesalazine 1 g daily (suppositories for proctitis, enemas for left-sided disease) PLUS oral mesalazine 2-4 g daily 1, 2
• Topical mesalazine is more effective than topical corticosteroids 1

Second-line therapy:

• Topical corticosteroids reserved for patients intolerant of topical mesalazine 1, 3
• Address proximal constipation with stool bulking agents or laxatives, as this can paradoxically worsen distal symptoms 1, 3, 2

Third-line therapy:

• Oral prednisolone 40 mg daily if no improvement with combination aminosalicylate therapy, tapered gradually over 8 weeks 1, 2
• Topical agents may be continued as adjunctive therapy 1

Left-Sided or Extensive Colitis

First-line therapy:

• Oral mesalazine 2-4 g daily or balsalazide 6.75 g daily for mild-to-moderate disease 1, 2
• Olsalazine 1.5-3 g daily has higher incidence of diarrhea in pancolitis; best reserved for left-sided disease 1

Second-line therapy:

• Prednisolone 40 mg daily when prompt response is required or mesalazine has failed, tapered over 8 weeks 1, 2
• Rapid steroid tapering (<8 weeks) is associated with early relapse and should be avoided 1, 2

Steroid-dependent disease:

• Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day for chronic active steroid-dependent disease 1
• Long-term corticosteroid use is undesirable and should be avoided 1

Severe Ulcerative Colitis (Hospitalized Patients)

Immediate management requires joint gastroenterology-surgical consultation 1:

• Intravenous corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) 1
• IV fluid and electrolyte replacement to correct dehydration 1, 3
• Subcutaneous heparin to reduce thromboembolism risk 1, 3
• Blood transfusion to maintain hemoglobin >10 g/dL 1
• Nutritional support (enteral or parenteral) if malnourished 1, 3

Monitoring requirements:

• Daily physical examination for abdominal tenderness and rebound 1
• Vital signs four times daily 1
• Stool chart documenting frequency, character, and blood 1
• Laboratory monitoring (CBC, ESR/CRP, electrolytes, albumin, liver function) every 24-48 hours 1
• Daily abdominal radiography if colonic dilatation (transverse colon >5.5 cm) detected 1

Refractory severe disease:

• Ciclosporin for severe steroid-refractory colitis 1
• Infliximab 5 mg/kg at weeks 0,2, and 6 for moderately-to-severely active disease with inadequate response to conventional therapy 4, 5
• Inform patients of 25-30% chance of needing colectomy 1

Crohn's Disease (Ileal/Ileocolonic/Colonic)

Mild disease:

• High-dose mesalazine 4 g/daily may be sufficient initial therapy for mild ileocolonic Crohn's disease 1, 3

Moderate-to-severe disease:

• Oral prednisolone 40 mg daily, tapered over 8 weeks 1
• Budesonide 9 mg daily for isolated ileocecal disease with moderate activity (marginally less effective than prednisolone) 1

Severe disease:

• Intravenous corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) 1

Maintenance Therapy

Lifelong maintenance is generally recommended to reduce relapse risk and potentially reduce colorectal cancer risk 1, 2:

• Aminosalicylates (mesalazine, balsalazide, olsalazine) for all patients, especially those with left-sided or extensive disease 1
• Azathioprine or mercaptopurine for steroid-dependent disease 1, 2
• Discontinuation may be reasonable only for distal disease in remission for 2 years in patients averse to medication 1

Critical Pitfalls to Avoid

• Never use monotherapy when combination therapy is indicated: topical plus oral aminosalicylates are more effective than either alone for distal disease 1, 2
• Do not taper steroids rapidly: prednisolone should be reduced gradually over 8 weeks to prevent early relapse 1, 2
• Address constipation in distal colitis: proximal constipation can worsen diarrhea symptoms and requires laxative therapy 1, 3, 2
• Avoid bulk-forming laxatives (psyllium) in severe constipation as they may worsen impaction 6
• Do not delay corticosteroids while awaiting stool cultures in severe presentations 1
• Assess for hepatosplenic T-cell lymphoma risk: particularly in male adolescents/young adults with Crohn's disease or ulcerative colitis receiving azathioprine/mercaptopurine with TNF-blockers 4, 7