What is the initial approach to treating colitis in the Emergency Room (ER)?

Initial ER Management of Colitis

For patients presenting to the ER with colitis, immediately initiate aggressive supportive care with IV fluids, electrolyte correction, and thromboprophylaxis with low-molecular-weight heparin, while simultaneously assessing hemodynamic stability to determine if emergency surgical intervention is required. 1, 2

Immediate Stabilization and Assessment

Hemodynamic Evaluation

• Unstable patients require immediate surgical consultation and potential emergency exploration according to damage control principles 1
• Assess for life-threatening complications: free perforation, massive hemorrhage, toxic megacolon with shock 1
• Perform serial abdominal examinations and obtain imaging (CT) to identify pneumoperitoneum, free fluid, or colonic distension 1, 2

Initial Supportive Care

• Administer adequate IV fluid resuscitation to correct volume depletion and electrolyte abnormalities 1, 2
• Start LMWH thromboprophylaxis immediately due to high thrombotic risk in acute colitis 1
• Correct anemia with transfusion if hemoglobin <10.5 g/dL 3
• NPO status initially, then advance diet as tolerated 2

Medical Management Algorithm

Severity Stratification

Use Truelove and Witts criteria to classify severity: severe disease = bloody stools ≥6/day PLUS tachycardia >90/min OR fever >37.8°C OR hemoglobin <10.5 g/dL OR ESR >30 mm/h 3

Antibiotic Therapy

• Do NOT routinely administer antibiotics in uncomplicated colitis 1
• Give antibiotics ONLY for: superinfection, intra-abdominal abscesses, sepsis, or suspected toxic megacolon 1, 2
• When indicated, target Gram-negative aerobes, Gram-positive streptococci, and anaerobes 2

Corticosteroid Therapy for Acute Severe Colitis

• Immediately start IV hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily without waiting for stool cultures 3
• Do not delay treatment for infectious workup results 3
• Limit IV corticosteroids to maximum 7-10 days 3
• If no improvement after 3-5 days, escalate to rescue therapy or surgery—do not extend steroids beyond 10 days 3, 4

Rescue Therapy (for corticosteroid non-responders at 3-5 days)

Two equally effective options 3, 4:

• Infliximab 5 mg/kg IV (preferred if patient already on immunosuppressives, allows maintenance therapy) 4
• Cyclosporine 2 mg/kg IV (rapid onset, short half-life, useful for imminent colectomy risk) 4

Surgical Indications

Absolute Emergency Surgery (Immediate)

Operate immediately for 1, 3:

• Free perforation with generalized peritonitis
• Life-threatening hemorrhage with persistent hemodynamic instability despite resuscitation
• Toxic megacolon with perforation, massive bleeding, clinical deterioration, or shock
• Pneumoperitoneum with free fluid in acutely unwell patients 1

Urgent Surgery (24-48 hours)

Do not delay surgery for 1, 2:

• Toxic megacolon without improvement after 24-48 hours of medical treatment
• Clinical deterioration or biochemical worsening despite maximal medical therapy
• Failure to respond to second-line rescue therapy 1

Surgical Approach

• Subtotal colectomy with end ileostomy is the procedure of choice for acute severe ulcerative colitis requiring emergency surgery 1, 5
• Open approach for hemodynamically unstable patients 1
• Laparoscopic approach acceptable for stable patients if expertise available 1

Nutritional Support

• Initiate nutritional support (enteral preferred, parenteral if contraindicated) as soon as possible 1, 2
• Reserve total parenteral nutrition for severely malnourished patients unable to tolerate enteral feeding, those with high-output fistulas, severe hemorrhage, or intestinal ischemia 2

Multidisciplinary Coordination

• Involve colorectal surgery from admission for joint care with gastroenterology 3, 6
• Early surgical consultation prevents delayed surgery and associated high morbidity 3
• Inform patients of 25-30% colectomy risk 3

Critical Pitfalls to Avoid

• Never delay surgery in critically ill patients with toxic megacolon—mortality increases significantly with perforation 2, 3
• Do not extend IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery 3
• Do not routinely give antibiotics without specific indication—this is not standard IBD management 1
• Avoid prolonged ineffective medical treatment in non-responders—delayed surgery increases complications and mortality 6
• Do not defer colectomy for rescue therapy if patient has inadequate response 4