What are the non-pharmacological treatment options for a patient with colitis?

Non-Pharmacological Treatment for Colitis

For patients with ulcerative colitis, non-pharmacological interventions should focus on nutritional support if malnourished (preferably enteral over parenteral nutrition), thromboembolism prophylaxis with subcutaneous low-molecular-weight heparin during acute flares, and avoidance of medications that precipitate colonic dilatation (anticholinergics, anti-diarrhoeals, NSAIDs, and opioids). 1

Essential Supportive Measures in Acute Severe Colitis

Nutritional Management:

• Provide enteral nutrition for malnourished patients, which is associated with significantly fewer complications than parenteral nutrition (9% vs 35% complication rates) 1
• Bowel rest through IV nutrition does not alter clinical outcomes and should not be routinely implemented 1
• Maintain adequate hydration and monitor for dehydration, particularly during acute flares 1

Thromboembolism Prevention:

• Administer subcutaneous prophylactic low-molecular-weight heparin to all hospitalized patients with acute severe colitis 1
• The risk of thromboembolism is substantially increased during disease flares, independent of other traditional risk factors 1

Medication Withdrawal:

• Immediately discontinue anticholinergic drugs, anti-diarrhoeal agents, non-steroidal anti-inflammatory drugs, and opioids, as these medications risk precipitating toxic megacolon 1

Dietary Interventions for Specific Symptoms

For Constipation in Colitis:

• Increase water and fiber intake as first-line dietary modifications 1
• Consider fermented milk containing probiotics and prebiotic fiber, which has demonstrated efficacy in increasing complete bowel movements and improving stool consistency in controlled trials 1
• Probiotics can be extensively recommended as adjuvant treatment due to their favorable safety profile 1

General Dietary Considerations:

• Provide judicious dietary instructions tailored to individual symptom patterns 1
• Review concomitant medications that could alter the gut microbiome (proton pump inhibitors, antibiotics) and assess their continued necessity 1

Complementary and Alternative Therapies

Evidence-Based Herbal Options:

• Curcumin shows promise for maintenance therapy in ulcerative colitis 2
• Plantago ovata (psyllium) has demonstrated benefit for UC maintenance 2
• Wormwood may be effective in Crohn's disease 2

Mind-Body Interventions:

• Psychological therapies including psychotherapy, hypnotherapy, and relaxation techniques may improve some symptoms, though effects are most evident in patients with overt psychiatric disorders or stress-exacerbated symptoms 1
• These interventions have no effect on constipation or constant abdominal pain 1
• Mind-body therapy and self-intervention strategies show benefit specifically in ulcerative colitis 2
• Efficacy has not been definitively established and should be regarded as treatment options after pharmacotherapy failure or as adjuncts 1

Acupuncture:

• May provide benefit in both ulcerative colitis and Crohn's disease, though evidence remains limited 2

Physical Activity and Exercise

• Prescribe tailored physical activity starting at low intensity and gradually increasing based on tolerance 3
• Recommend moderate aerobic exercise 3-5 times weekly, adapted to functional status 3
• Physical activity helps offset negative consequences of chronic pain on the body, improving physical function and quality of life 1

Critical Multidisciplinary Approach

Essential Team Collaboration:

• Establish close working relationship between gastroenterologists and colorectal surgeons from the time of admission for acute severe colitis 1
• Early surgical referral and communication with specialist colorectal surgical and stoma care teams is advised, as delay in surgery increases risk of surgical complications 1

Common Pitfalls to Avoid

Do Not:

• Use bowel rest routinely, as it provides no benefit 1
• Continue anti-diarrhoeal medications, NSAIDs, opioids, or anticholinergics during acute flares due to toxic megacolon risk 1
• Delay surgical consultation in acute severe colitis, as this increases morbidity and mortality 1
• Rely solely on high-fiber diets, as they may worsen abdominal discomfort in many patients and are contraindicated in diarrhea-predominant disease 1

Important Caveats:

• The benefit of most non-pharmacological treatments is limited to specific symptoms rather than the complete disease spectrum 1
• When documented, benefit typically occurs in only 10-20% of patients 1
• Non-pharmacological interventions should complement, not replace, appropriate pharmacological therapy and timely surgical intervention when indicated 1