What is the best course of treatment for an adult patient with a history of inflammatory bowel disease (IBD) presenting with severe symptoms of acute severe ulcerative colitis (ASUC) or fulminant colitis, and known proctocolitis with gas-filled loops of both large and small bowel?

Management of Proctocolitis with Gas-Filled Bowel Loops in IBD

Immediate Assessment for Toxic Megacolon

This patient requires urgent evaluation for toxic megacolon and immediate surgical consultation, as gas-filled loops in the setting of known proctocolitis may represent a life-threatening complication requiring emergency subtotal colectomy. 1, 2

Critical Initial Steps

• Check vital signs immediately and calculate shock index (heart rate ÷ systolic blood pressure)—values >1 indicate hemodynamic instability requiring urgent intervention 3, 4
• Obtain urgent CT scan of abdomen/pelvis rather than plain X-ray if severe complications (perforation, toxic megacolon) are suspected, as CT provides superior diagnostic information 1, 3
• Measure hemoglobin/hematocrit, CRP, albumin, electrolytes, and coagulation parameters 1
• Assess for signs of systemic toxicity: fever >37.8°C, tachycardia >90 bpm, leukocytosis, or anemia 1, 3

Defining Toxic Megacolon

Toxic megacolon is characterized by radiographic colonic distension (particularly transverse colon >6 cm) with systemic toxicity including fever, tachycardia, neutrophil leukocytosis, and anemia 1, 2. Gas-filled loops of both large and small bowel in the context of known proctocolitis should raise immediate concern for this devastating complication. 2, 5

Surgical Indications - Do Not Delay

Emergency subtotal colectomy with end ileostomy is indicated for: 1, 2

• Life-threatening hemorrhage with hemodynamic instability
• Toxic megacolon with systemic toxicity
• Free perforation or generalized peritonitis
• Failure to respond to medical therapy within 48-72 hours

Critical Timing Considerations

Surgery should not be delayed beyond 24-48 hours in patients with toxic megacolon and systemic toxicity, as delay is associated with dramatically increased mortality (27-57% with perforation). 3, 2 Prolonged admission prior to surgery is the only significant predictor of postoperative complications 1. In one study, colectomy delayed to 6-11 days showed adjusted odds ratios for postoperative death of 2.12 and 2.89 respectively compared to surgery within 3 days 1.

Medical Management Algorithm (If No Immediate Surgical Indications)

If Acute Severe Ulcerative Colitis Without Toxic Megacolon

Initiate IV corticosteroids (methylprednisolone 60 mg daily or hydrocortisone 100 mg four times daily) and assess response at 3 days using objective criteria 1:

• Day 3 assessment: If >8 bowel movements/day OR 3-8 bowel movements/day AND CRP >45 mg/L, patient requires rescue therapy 1
• Rescue therapy options (after surgical review confirms colectomy not immediately required): IV infliximab 5 mg/kg OR IV ciclosporin 2 mg/kg/day 1

Infliximab Dosing Optimization

For patients with low albumin (<35 g/L) or high CRP (>50 mg/L), consider accelerated infliximab dosing with repeat infusion at 3-5 days if insufficient response, as these factors independently correlate with lower drug concentrations 1. Accelerated dosing (3 doses over median 24 days) reduced colectomy rates from 40% to 6.7% in steroid-refractory patients 1.

Day 7 Decision Point

If no response within 7 days of rescue therapy, proceed to subtotal colectomy and ileostomy. 1 Approximately 66% respond to steroids; 34% require colectomy 3. Timely decision-making is essential—prolonged medical therapy in non-responders increases surgical complications and mortality 1.

Common Pitfalls to Avoid

• Do not attempt medical rescue therapy with high-dose steroids or biologics in established toxic megacolon with systemic toxicity—this delays necessary surgery and increases mortality 2
• Do not delay CT imaging in favor of plain radiography when complications are suspected 1, 3
• Do not continue medical therapy beyond 48-72 hours in patients showing deterioration or lack of improvement 1, 3
• Do not perform single-stage proctocolectomy with IPAA in the emergency setting—subtotal colectomy with end ileostomy and preservation of rectum is the appropriate emergency procedure 1, 2

Multidisciplinary Approach

Early involvement of colorectal surgery is mandatory—surgical input helps patients understand that colectomy is an important treatment option, not an outcome to be avoided at any cost 1. Joint gastroenterology-surgery decision-making prevents unnecessary delays that worsen outcomes 1.