What is the initial treatment for a stable patient with colitis in the emergency room (ER)?

Initial Treatment of Stable Colitis in the Emergency Department

For hemodynamically stable patients presenting with acute severe ulcerative colitis in the ER, immediately initiate intravenous corticosteroids (hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily) along with aggressive supportive care, without waiting for stool culture results or other screening tests. 1, 2

Immediate Assessment and Stabilization

Severity Classification

• Use Truelove and Witts' criteria to classify disease severity: severe disease is defined as bloody stool frequency ≥6/day plus at least one of: tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5 g/dL, or ESR >30 mm/h (CRP >30 mg/L can substitute). 1
• Obtain baseline laboratory tests including complete blood count, CRP, albumin, urea, electrolytes, and liver function tests. 2

Diagnostic Workup

• Perform unprepared flexible sigmoidoscopy with biopsies to confirm diagnosis, assess severity, and exclude cytomegalovirus infection. 1, 2
• Obtain stool cultures and test for Clostridium difficile toxin, which is more prevalent in severe UC and associated with increased morbidity and mortality. 2

Initial Medical Management

Corticosteroid Therapy

• Start intravenous corticosteroids immediately without delaying for screening test results: hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily. 1, 2
• Limit treatment duration to 7-10 days maximum, as extending beyond this carries no additional benefit. 1, 2
• Overall response rate to IV corticosteroids is 67%, with 33% requiring colectomy. 1, 2

Essential Supportive Care

• Administer adequate volume of intravenous fluids with electrolyte replacement, including potassium supplementation of at least 60 mmol/day to prevent hypokalemia and toxic dilatation. 3, 2
• Initiate subcutaneous low-molecular-weight heparin for thromboprophylaxis immediately—rectal bleeding is NOT a contraindication. 3, 2
• Transfuse blood to maintain hemoglobin above 8-10 g/dL. 2
• Correct electrolyte abnormalities and anemia. 3
• Withdraw anticholinergic, anti-diarrheal, NSAID, and opioid drugs which may precipitate colonic dilatation. 2

Nutritional Support

• Provide nutritional support (parenteral or enteral, according to GI function) in malnourished patients as soon as possible, with enteral nutrition preferred over parenteral. 3, 2

Antibiotic Considerations

• Do not routinely administer antibiotics, but give them if superinfection is suspected or in the presence of intra-abdominal abscesses. 3
• When indicated, target Gram-negative aerobic and facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli. 3

Multidisciplinary Approach

• Evaluate all hemodynamically stable patients in a multidisciplinary approach with the gastroenterologist to decide on options for initial medical treatment. 4
• Involve colorectal surgery from admission, with early surgical consultation to prevent delayed surgery and associated high morbidity. 1, 2
• Inform patients of 25-30% chance of needing colectomy. 1

Response Assessment and Next Steps

Day 3 Evaluation

• Perform formal assessment of response on day 3 to identify patients needing rescue therapy. 2
• If no improvement or deterioration within 48-72 hours from initiation of medical therapy, consider second-line rescue therapy (infliximab 5 mg/kg IV or cyclosporine 2 mg/kg IV) or surgery. 4, 1

Rescue Therapy Options

• For patients not responding to IV corticosteroids after 3-5 days, two equally effective rescue options exist: infliximab 5 mg/kg IV or cyclosporine 2 mg/kg IV. 1

Immediate Surgical Indications

Emergency surgical exploration is mandatory in the following scenarios:

• Hemodynamically unstable patients (according to damage control principles). 4
• Colonic perforation with generalized peritonitis. 4, 2
• Toxic megacolon complicated by perforation, massive bleeding, clinical deterioration, or signs of shock. 4, 2
• Life-threatening hemorrhage with persistent hemodynamic instability despite resuscitation. 4, 1
• Radiological signs of pneumoperitoneum and free fluid within the peritoneal cavity in acutely unwell patients. 4

Subtotal colectomy with ileostomy is the surgical treatment of choice for acute severe ulcerative colitis patients presenting with massive colorectal hemorrhage or non-responders to medical treatment. 4

Critical Pitfalls to Avoid

• Do not delay corticosteroid treatment while waiting for stool microbiology results. 2
• Do not delay surgery in critically ill patients with toxic megacolon, as this increases risk of perforation with high mortality. 4, 1
• Do not extend IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery. 1
• Overall mortality of ASUC is 1%, but significantly higher in patients >60 years with comorbidities. 1, 2

Mild-to-Moderate Disease (Non-Severe Presentation)

If the patient presents with mild-to-moderate distal UC rather than acute severe disease:

• For proctitis or left-sided disease, initiate topical mesalamine 1 g daily combined with oral mesalamine 2-4 g daily. 1
• For proctitis specifically, mesalamine 1g suppository once daily is first-line. 1
• If no improvement on combination therapy, escalate to oral prednisolone 40 mg daily with continued topical agents. 1