What is the immediate management for a patient with abdominal distension due to ulcerative colitis?

Immediate Management of Abdominal Distension in Ulcerative Colitis

A patient with ulcerative colitis presenting with abdominal distension requires immediate hospitalization, daily plain abdominal radiographs to assess for toxic megacolon (transverse colon >5.5 cm), and urgent initiation of intravenous corticosteroids while maintaining close surgical consultation, as this represents a potentially life-threatening complication with high risk for perforation and mortality. 1, 2

Initial Assessment and Monitoring

Abdominal distension in UC is a red flag requiring aggressive intervention:

• Perform daily plain abdominal radiographs immediately to measure transverse colon diameter—toxic megacolon is defined as >5.5 cm and carries significant mortality risk 2, 1
• GI distension on plain films identifies a subgroup at higher risk for toxic megacolon (53% prevalence in severe UC) and multiple organ dysfunction syndrome 3
• Monitor vital signs four times daily: pulse rate, temperature, blood pressure to detect early deterioration 2, 1
• Daily laboratory monitoring: complete blood count, CRP/ESR, electrolytes, albumin, and liver function tests every 24-48 hours 2, 1
• Maintain detailed stool chart documenting frequency, character, and presence of blood 2, 1

Immediate Medical Management

Start intensive intravenous therapy without delay:

• Initiate IV hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily immediately—do not wait for stool culture results 1, 2
• Aggressive IV fluid and electrolyte replacement to correct dehydration and electrolyte imbalances 2
• Subcutaneous heparin for thromboembolism prophylaxis (IBD patients have exceptionally high thrombotic risk) 2
• Blood transfusion to maintain hemoglobin >10 g/dl 2
• Nutritional support (enteral or parenteral) if malnourished 2

Critical pitfall: Persistent GI distension despite medical therapy predicts poor response and need for surgery—do not delay surgical consultation 3

Surgical Consultation and Indications

Joint medical-surgical management is mandatory from admission:

• Immediate surgical consultation with colorectal surgeon experienced in IBD management 2, 1
• Inform patient of 25-30% chance of requiring colectomy 2, 1

Absolute indications for emergency surgery (do not delay):

• Free perforation with generalized peritonitis 2, 1
• Life-threatening hemorrhage with hemodynamic instability 2, 1
• Toxic megacolon with clinical deterioration, signs of shock, or no improvement after 24-48 hours of medical treatment 2, 1
• Development of multiple organ dysfunction syndrome 3

Subtotal colectomy with ileostomy is the procedure of choice for emergency surgery in this setting 2, 1

Response Assessment and Escalation

Evaluate response to IV corticosteroids at 3-5 days:

• If no improvement or deterioration within 48-72 hours, consider second-line rescue therapy or surgery 2, 1
• Do not extend IV corticosteroids beyond 7-10 days without escalating—no additional benefit and increases surgical morbidity 1

Rescue therapy options for steroid non-responders (equally effective):

• Infliximab 5 mg/kg IV OR cyclosporine 2 mg/kg IV 1, 4
• However, in the presence of significant abdominal distension suggesting impending toxic megacolon, surgery should not be deferred for rescue therapy trials 3, 4

Key Clinical Pitfalls to Avoid

• Never delay corticosteroids while awaiting stool cultures—acute onset UC is difficult to distinguish from infectious colitis, but treatment must not be delayed 2, 1
• Do not underestimate persistent GI distension—this predicts toxic megacolon development in 19% of cases (4/21 patients in prospective studies) and MODS in 10% 3
• Avoid delaying surgery in critically ill patients—mortality of acute severe UC is 1% overall but significantly higher with delayed surgery and in patients >60 years 1, 2
• Maintain low threshold for repeat abdominal radiographs if any clinical deterioration occurs, even if initial film was normal 2