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

Emergency Room Treatment for Colitis

For hemodynamically stable patients presenting to the ER with acute severe colitis, immediately initiate IV corticosteroids (hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily) along with aggressive IV fluid resuscitation, electrolyte correction, and low-molecular-weight heparin thromboprophylaxis—do not wait for stool culture results. 1, 2

Immediate Stabilization (First Actions)

Hemodynamic Assessment

• Assess hemodynamic stability first to determine if emergency surgical intervention is required 1
• Unstable patients require immediate surgical consultation and potential emergency exploration 1
• Look specifically for life-threatening complications: free perforation, massive hemorrhage, or toxic megacolon with shock 1

Initial Supportive Care

• Start aggressive IV fluid resuscitation to correct volume depletion 1, 2
• Correct electrolyte abnormalities, particularly potassium supplementation of at least 60 mmol/day to prevent hypokalemia and toxic dilatation 2
• Initiate subcutaneous low-molecular-weight heparin immediately for thromboprophylaxis—rectal bleeding is NOT a contraindication 1, 2

Medical Management Algorithm

For Hemodynamically Stable Patients with Severe Disease

• Start IV corticosteroids immediately without waiting for stool cultures: hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily 1, 2, 3
• Disease severity is defined by Truelove and Witts' criteria: 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) 2, 3
• Limit IV corticosteroids to maximum 7-10 days—extending beyond this provides no additional benefit 1, 2, 3

Antibiotic Use (Critical Distinction)

• Do NOT routinely administer antibiotics in uncomplicated colitis 1
• Give antibiotics ONLY for: superinfection, intra-abdominal abscesses, sepsis, or suspected toxic megacolon 1

Nutritional Support

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

Diagnostic Evaluation

Essential Testing

• Obtain baseline labs: complete blood count, CRP, albumin, urea, electrolytes, and liver function tests 2
• Perform unprepared flexible sigmoidoscopy with biopsies to confirm diagnosis, assess severity, and exclude cytomegalovirus infection 2, 3
• Obtain stool cultures and test for Clostridium difficile toxin, as it is more prevalent in severe UC and associated with increased morbidity and mortality 2

Imaging

• Obtain CT scan to identify pneumoperitoneum, free fluid, or colonic distension 1
• Perform serial abdominal examinations to monitor for deterioration 1

Response Assessment and Escalation

Expected Response

• Overall response rate to IV corticosteroids is 67%, with 33% requiring colectomy 2, 3
• If no improvement after 3-5 days, escalate to rescue therapy or surgery—do not extend steroids beyond 10 days 1, 2

Rescue Therapy Options (After 3-5 Days of Non-Response)

• Two equally effective options: infliximab 5 mg/kg IV or cyclosporine 2 mg/kg IV 3

Surgical Indications

Immediate Surgery Required For:

• Free perforation with generalized peritonitis 1, 2, 3
• Life-threatening hemorrhage with persistent hemodynamic instability despite resuscitation 1, 3
• Toxic megacolon with perforation, massive bleeding, clinical deterioration, or shock 1, 2, 3

Urgent Surgery Indicated For:

• Toxic megacolon without improvement after 24-48 hours of medical treatment 1, 3
• Clinical deterioration or biochemical worsening despite maximal medical therapy 1
• Failure to respond to second-line rescue therapy 1

Surgical Procedure

• Subtotal colectomy with end ileostomy is the procedure of choice for acute severe ulcerative colitis requiring emergency surgery 1, 2

Multidisciplinary Coordination

• Involve colorectal surgery from admission for joint care with gastroenterology 1, 3
• Early surgical consultation prevents delayed surgery and associated high morbidity 1, 3
• Inform patients of 25-30% colectomy risk 1, 3
• Overall mortality of acute severe UC is 1%, but significantly higher in patients >60 years with comorbidities 3

Critical Pitfalls to Avoid

• Never delay corticosteroid treatment while waiting for stool microbiology results 2, 3
• Never delay surgery in critically ill patients with toxic megacolon—mortality increases significantly with perforation 1, 2, 3
• Never extend IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery 1, 2, 3
• Never routinely give antibiotics without specific indication—this is not standard IBD management 1