What is the treatment for a patient with fulminant colitis?

Treatment of Fulminant Colitis

Initiate intravenous corticosteroids immediately as first-line therapy, assess response by day 3, and proceed to rescue therapy with infliximab or ciclosporin if inadequate response—or proceed directly to colectomy if toxic megacolon, perforation, or severe systemic toxicity is present. 1

Initial Management and Supportive Care

• Start IV methylprednisolone 40-60 mg/day (or hydrocortisone 100 mg four times daily) immediately after fluid resuscitation 1, 2
• Provide aggressive IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day to prevent hypokalaemia and toxic dilatation 2
• Initiate low-molecular-weight heparin for thromboprophylaxis—rectal bleeding is NOT a contraindication 2
• Restrict oral intake and consider parenteral nutrition if malnourished 1, 3
• Perform unprepared flexible sigmoidoscopy to confirm disease activity, assess severity, and exclude CMV colitis and C. difficile infection 1, 2

Critical Diagnostic Exclusions

• Rule out C. difficile and CMV infection before escalating immunosuppression, as unrecognized infection dramatically increases morbidity and mortality 1, 4
• Obtain daily monitoring: stool frequency, vital signs, complete blood count, CRP, albumin, and electrolytes 2
• Plain abdominal X-ray to assess for colonic dilatation >5.5 cm (toxic megacolon) and mucosal islands, which predict higher colectomy rates 1

Response Assessment and Decision Points

Day 3 Assessment (Oxford Criteria):

• >8 stools per day OR 3-8 stools per day with CRP >45 mg/L predicts 85% colectomy rate—proceed to rescue therapy 1
• Approximately 67% of patients respond to IV corticosteroids alone, but formal assessment at day 3 is mandatory to identify steroid failures early 1

Day 7 Assessment:

• >3 stools per day or visible blood indicates 40% colectomy rate in ensuing months—consider rescue therapy or surgery 1
• Maximum duration of IV corticosteroids is 7-10 days; prolonged courses offer no benefit and increase toxicity 2

Rescue Therapy Options (When Steroids Fail by Day 3-5)

Choose between infliximab, ciclosporin, or surgery based on:

Infliximab (Preferred in Most Cases)

• Dose: 5 mg/kg IV at weeks 0,2, and 6 1
• Effective in 60-67% of patients for avoiding short-term colectomy 1
• Retrospective data suggest lower colectomy rates with infliximab compared to ciclosporin 1
• Preferred if patient has prior thiopurine failure, as ciclosporin requires bridging to thiopurines 1

Ciclosporin (Alternative Rescue)

• Dose: 2 mg/kg/day IV (equivalent efficacy to 4 mg/kg with fewer adverse events) 1, 5
• Short-term response rate of 76-85%, but only 50% avoid colectomy at 5 years 5, 6, 7
• Do NOT use ciclosporin in patients with prior inadequate response to thiopurines (59% colectomy rate vs. thiopurine-naïve patients) 1
• Requires bridging to azathioprine for maintenance in responders 1, 8

Comparative Efficacy

• The CYSIF trial showed equivalent efficacy: 85% response by day 7, with colectomy rates of 18% (ciclosporin) vs. 21% (infliximab) by day 98 1
• Both agents have comparable adverse event profiles when used appropriately 1

Critical Pitfalls to Avoid

• NEVER use sequential rescue therapy (ciclosporin after infliximab or vice versa)—this increases sepsis risk to 16% and only achieves 25-40% success 1
• Following failure of one rescue therapy, proceed directly to surgery rather than attempting a second medical rescue 1
• Antibiotics should NOT be routinely administered unless specific infection is identified—controlled trials show no benefit 1
• Avoid anti-diarrheal medications, as they may precipitate toxic megacolon 2

Surgical Indications (Immediate Colectomy Required)

Proceed to surgery without delay if:

• Toxic megacolon without improvement after 24-48 hours of medical therapy 1
• Perforation or massive hemorrhage 1, 2
• Failure of rescue therapy after 4-7 days 1, 2
• Severe systemic toxicity with physiological derangement despite medical therapy 1

Surgical Procedure:

• Subtotal colectomy with end ileostomy is the procedure of choice (part of three-stage approach) 1, 2
• Laparoscopic approach is safe in experienced hands with improved short-term outcomes 1
• Diverting loop ileostomy with colonic lavage is an alternative to total colectomy for C. difficile-associated fulminant colitis 1

Special Considerations

For C. difficile Fulminant Colitis:

• Treat with high-dose vancomycin 500 mg every 6 hours (oral and/or by enema) PLUS IV metronidazole 500 mg every 8 hours 1
• Total colectomy is preferred over partial colectomy if surgery is required 1

Tacrolimus:

• Insufficient data for acute severe/fulminant colitis—reserve for steroid-refractory moderate-to-severe disease when infliximab/ciclosporin unavailable 4
• Do NOT use as first-line rescue therapy 4

Mortality and Prognosis:

• Overall mortality of fulminant colitis is 1%, but significantly higher in patients >60 years and those with comorbidities 2
• Early surgical consultation from admission is mandatory—delayed surgery increases morbidity 1, 2