What are the treatment options for a patient with colitis, considering the severity of the condition and potential complications?

Treatment of Colitis

Treatment of colitis must be stratified by disease type (ulcerative colitis vs. Crohn's disease), anatomic extent, and severity, with immediate intravenous corticosteroids for severe presentations and joint gastroenterology-surgical management to prevent the 25-30% risk of colectomy. 1

Initial Assessment and Severity Classification

Classify severity using Truelove and Witts' criteria: 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

For Crohn's disease, assess the site (ileal, ileocolonic, colonic), pattern (inflammatory, stricturing, fistulating), and activity before treatment decisions, while considering alternative explanations such as bacterial overgrowth, bile salt malabsorption, or fibrotic strictures. 2

Ulcerative Colitis Treatment Algorithm

Mild to Moderate Distal Disease (Proctitis or Left-Sided)

First-line therapy is topical mesalamine 1g suppository daily combined with oral mesalamine 2-4g daily. 1 For proctitis specifically, mesalamine 1g suppository once daily is the preferred initial approach. 1

If no improvement occurs on combination therapy, escalate to oral prednisolone 40mg daily with continued topical agents as adjunctive therapy. 1

Acute Severe Ulcerative Colitis

Immediately initiate intravenous corticosteroids (hydrocortisone 100mg four times daily OR methylprednisolone 40-60mg daily) without waiting for stool culture results. 1 This aggressive approach is critical because delaying treatment while awaiting microbiology results worsens outcomes. 1

The expected response rate to IV corticosteroids is 67%, with 33% requiring colectomy. 1 Treatment duration should be limited to 7-10 days maximum, as extending beyond this carries no additional benefit. 1

Critical monitoring requirements include: 2

• Vital signs four times daily (more often if deteriorating)
• Daily stool chart documenting number, character, and presence of blood
• FBC, ESR/CRP, electrolytes, albumin, and liver function tests every 24-48 hours
• Daily abdominal radiography if colonic dilatation (transverse colon diameter >5.5cm) detected at presentation
• Physical examination daily to evaluate abdominal tenderness and rebound

Essential supportive care includes: 2

• IV fluid and electrolyte replacement with blood transfusion to maintain hemoglobin >10 g/dl
• Subcutaneous heparin for thromboembolism prophylaxis (markedly elevated risk during flares)
• Nutritional support (enteral or parenteral) if malnourished

Rescue Therapy for Steroid-Refractory Disease

For patients not responding to IV corticosteroids after 3-5 days, use either infliximab 5mg/kg IV or cyclosporine 2mg/kg IV—both are equally effective rescue options. 1 Perform unprepared flexible sigmoidoscopy with biopsies to exclude cytomegalovirus infection, which associates with steroid-refractory disease. 1

Surgical Indications

Surgery is mandatory for: 1

• Free perforation with generalized peritonitis
• Life-threatening hemorrhage with hemodynamic instability despite resuscitation
• Toxic megacolon complicated by perforation, massive bleeding, clinical deterioration, or signs of shock

Surgery is indicated for: 1

• Toxic megacolon with no clinical improvement after 24-48 hours of medical treatment
• Significant recurrent gastrointestinal bleeding
• No improvement after 48-72 hours of medical treatment or failure of second-line rescue therapy

Joint care by gastroenterologist and colorectal surgeon from admission is essential, with early surgical consultation to prevent delayed surgery and associated high morbidity. 1 Patients should be informed of the 25-30% chance of needing colectomy. 2

Crohn's Disease Treatment Algorithm

Mild Ileocolonic Disease

High-dose mesalazine 4g daily may be sufficient initial therapy. 2

Moderate to Severe Crohn's Disease

For moderate to severe disease, or mild to moderate ileocolonic disease that failed oral mesalazine, use oral prednisolone 40mg daily. 2 Prednisolone should be reduced gradually over 8 weeks according to severity and patient response—more rapid reduction is associated with early relapse. 2

For isolated ileo-caecal disease with moderate activity, budesonide 9mg daily is appropriate but marginally less effective than prednisolone. 2

Severe Crohn's Disease

Intravenous steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) are appropriate for severe disease. 2 Concomitant intravenous metronidazole is often advisable because distinguishing between active disease and septic complications can be difficult. 2

For colonic Crohn's disease, sulphasalazine 4g daily is effective but cannot be recommended as first-line therapy due to high incidence of side effects. 2

Alternative and Adjunctive Therapies

Elemental or polymeric diets are less effective than corticosteroids but may be used in selected patients with contraindications to corticosteroid therapy or who prefer to avoid such therapy. 2 Total parenteral nutrition is appropriate adjunctive therapy in complex, fistulating disease. 2

Maintenance Therapy

Lifelong maintenance therapy is generally recommended for all patients, especially those with left-sided or extensive disease, and those with distal disease who relapse more than once a year. 2 Patients with ulcerative colitis should normally receive maintenance therapy with aminosalicylates, azathioprine, or mercaptopurine to reduce the risk of relapse. 2

Discontinuation of medication may be reasonable for those with distal disease who have been in remission for 2 years and are averse to such medication, though maintenance therapy reduces the risk of colorectal cancer. 2

For moderate-to-severe disease requiring biologics, options include infliximab, adalimumab, vedolizumab, ustekinumab, or tofacitinib. 1 Continue with the agent successful in achieving induction, except corticosteroids. 1

Critical Pitfalls to Avoid

Never delay corticosteroid treatment while waiting for stool microbiology results in acute severe presentations. 1 The risk of untreated severe colitis far outweighs concerns about treating potential infectious colitis.

Never extend IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery. 1 This delay increases morbidity without improving outcomes.

Never delay surgery in critically ill patients with toxic megacolon, as this increases risk of perforation with high mortality. 1 Overall mortality of acute severe UC is 1%, but significantly higher in patients >60 years with comorbidities. 1