From the Guidelines
For a patient with colitis of the transverse and descending colon identified on CT abdomen and mildly elevated WBC (11.2), initial ED treatment should focus on stabilization and symptom management, with consideration of infectious causes of diarrhea and potential immune checkpoint inhibitor (ICI) colitis, as suggested by Best Practice Advice 1 from the American Gastroenterological Association (AGA) 1. Given the patient's presentation, it is crucial to exclude infectious causes of diarrhea before attributing the symptoms to other forms of colitis, such as ICI colitis, which may require different management strategies.
- Start with IV fluids for hydration and electrolyte replacement to stabilize the patient.
- Administer broad-spectrum antibiotics such as ciprofloxacin 400mg IV q12h plus metronidazole 500mg IV q8h to cover common colitis pathogens, but only after collecting stool studies including culture, C. difficile testing, and ova/parasites.
- For pain control, use acetaminophen 1000mg IV/PO q6h and avoid NSAIDs which can worsen colitis.
- Antiemetics like ondansetron 4mg IV q6h PRN can help manage nausea.
- The patient should be placed on bowel rest with clear liquids only initially.
- Monitor vital signs, abdominal exam findings, and laboratory values closely, considering the potential for rapid progression of ICI colitis as noted in Best Practice Advice 5 from the AGA 1. Once the acute colitis resolves, follow-up colonoscopy is essential as recommended to evaluate for underlying malignancy, especially considering the patient's colitis involves the transverse and descending colon. The patient should be discharged with oral antibiotics (ciprofloxacin 500mg BID and metronidazole 500mg TID for 7-10 days), instructions for a bland diet with gradual advancement, adequate hydration, and prompt follow-up with gastroenterology for colonoscopy scheduling, keeping in mind the guidelines for managing ICI colitis and its potential complications as outlined by the AGA 1.
From the Research
Treatment Approach
The patient's CT abdomen results indicate colitis of the transverse and descending colon, and the recommended follow-up colonoscopy upon resolution is to rule out underlying malignancy. Given the patient's symptoms and lab results (WBC 11.2, RBC 5.43, hematocrit 46.1), the treatment approach in the ED can be guided by the following:
- For infectious colitis, standard stool culture should be performed, and empiric treatment with antibiotics such as azithromycin may be considered for febrile dysenteric diarrhea 2.
- For ischemic colitis, treatment is supportive in less severe cases, with intravenous fluids and bowel rest, and broad-spectrum antibiotics should be initiated 3, 4.
- Intravenous fluid therapy is essential to replenish fluid volumes and restore homeostasis, and nurses play a crucial role in assessing patients' fluid status and administering and monitoring therapy 5.
Laboratory Testing and Diagnosis
- Standard stool culture should be performed in patients with infectious colitis to determine the underlying cause 2.
- Computed tomography (CT) scan of the abdomen and pelvis with oral and IV contrast and laboratory testing should be performed in patients with symptoms concerning for ischemia 3.
- Colonoscopy is the procedure of choice for diagnosis of ischemic colitis 3, 4.
Medications and Therapy
- Empiric treatment with antibiotics such as azithromycin may be considered for febrile dysenteric diarrhea 2.
- Broad-spectrum antibiotics should be initiated in cases of ischemic colitis 3, 4.
- Intravenous fluids and bowel rest are essential components of supportive care for ischemic colitis 3, 4.
- Ciprofloxacin may be considered as an adjunctive treatment for ulcerative colitis in patients responding poorly to conventional therapy 6.