Makindo Medical Notes

Treat with high-dose steroids for 3 days and then decide if rescue therapy such as Infliximab, Ciclosporin, or Colectomy is needed.

Initial Management Summary for Acute Severe Colitis

Determine if this fits criteria for Acute Severe Colitis with Truelove and Witts criteria. Administer IV fluids, monitor potassium, ensure hydration, and provide VTE prophylaxis. IV Hydrocortisone 100 mg every 6 hours for 3 days and review. PO steroids in milder cases. Test for and treat Clostridioides difficile infection if present. Stop opiates, anticholinergics, loperamide, or other drugs delaying bowel motility. Repeat AXR or CT abdomen if condition worsens to exclude perforation/megacolon. Ensure close liaison with Colorectal and Lower GI surgical teams. On Day 4, make a joint decision with surgeons on rescue therapy if the patient is not improving. Rescue therapies include Infliximab, Ciclosporin, or Colectomy.

About

• Acute severe colitis can lead to serious complications such as Megacolon and bowel perforation.
• The inflamed bowel tries to empty its contents, leading to symptoms.

Clinical

• Fever, malaise, anorexia.
• Frequent bowel motions with blood, pus, mucus, or a combination.
• Abdominal pain and tenderness.
• Assess if there is known inflammatory bowel disease (IBD) and the extent of the disease.

Causes

• Inflammatory bowel disease (IBD): Determine if there is known disease or symptoms over months, and assess disease extent with colonoscopy and histology.
• Pseudomembranous colitis: Consider if recent antibiotic use.
• Infectious: Ask about travel history and consider HIV.
• Food poisoning and typhoid should also be considered.

Extent of Ulcerative Colitis

Clinical Features

• Often toxic, feverish, dehydrated, and unwell.
• Rectal bleeding, diarrhoea, tenesmus, and lower abdominal crampy discomfort.
• Tachycardia that increases by 30 bpm on sitting suggests hypovolemia.
• Postural hypotension, abdominal distension, peritonism, and guarding may be present.
• Low JVP and poor capillary return indicate hypovolemia.

Key Questions

• How many bowel movements per day?
• Is there blood in the stools?
• Is there pyrexia?
• Is the pulse rate > 90 bpm?
• Is the ESR elevated?
• Is the hemoglobin level low?

Investigations

• FBC, U&E, LFTs, Mg, Ca, Amylase, Lactate, CRP, Glucose. Consider HIV, TB, and CMV testing.
• Stool samples for C. difficile toxins, Salmonella, Shigella, Campylobacter, and E. coli.
• Persistent diarrhoea >7 days in immunocompromised patients: test for Giardia, Cryptosporidium, and Isospora belli.
• For HIV patients: test for Microsporidia, Mycobacterium avium complex, and CMV.
• Perform Erect CXR and Abdominal X-ray, repeating daily if symptoms do not resolve.
• TPMT levels if considering starting Azathioprine.
• QuantiFERON status or PPD if rescue therapy is likely.
• If rescue therapy is needed, get relevant blood tests early so they can be started on Day 4.

Differential Diagnoses

• Acute viral gastroenteritis: Non-bloody, watery stool, mild disease, afebrile.
• Acute colitis due to bacterial infection: Consider IV or oral Ciprofloxacin and Metronidazole.
• Acute severe colitis due to Clostridioides difficile: Treat with Vancomycin PO QDS until test results are available.
• Acute colitis related to NSAID use.

Truelove and Witts criteria

Parameter	Mild	Moderate	Severe
Blood stools per day	< 4	4-6	> 6
Temperature (°C)	Afebrile		> 37.8
Heart rate (bpm)	Normal		> 90
Hemoglobin (g/dL)	> 11	10.5-11	< 10.5
ESR (mm/hr)	< 20	20-30	> 30

Management of Acute Severe Colitis Due to IBD

• Use Truelove and Witts criteria to assess severity and direct therapy.
• A stool frequency > 8 or a CRP > 45 on day 3 of admission predicts an 85% likelihood of requiring a colectomy.
• Initial treatment involves IV corticosteroids for severe cases, but one-third of patients may not respond.
• If no improvement after 72 hours of IV steroids, escalate to rescue therapy (e.g., Infliximab, Ciclosporin, or Surgery).
• Monitor for signs of megacolon or perforation, especially if abdominal symptoms worsen.
• Severe cases should receive daily reviews from gastroenterology and colorectal surgery teams, with decision-making by day 4 on the need for rescue therapy.
• Continue to provide fluids and correct electrolyte imbalances. Stop any medications that slow bowel motility.
• For patients with possible co-infection with C. difficile, give oral Vancomycin.
• Flexible sigmoidoscopy may be performed if necessary, with minimal air insufflation to reduce perforation risk.
• Abdominal X-rays may show mucosal islands ("thumb printing") or colonic dilation (diameter > 5.5 cm).

Rescue Therapy

• Infliximab: 5 mg/kg IV infusion, followed by additional infusions at 2 and 6 weeks, then every 8 weeks. Be cautious of latent TB or opportunistic infections.
• Ciclosporin: 2 mg/kg. Check magnesium and cholesterol levels before administration to avoid nerve damage. Patients may be converted to Azathioprine afterward.
• Colectomy: If medical management fails, surgical intervention may be necessary. Delaying colectomy in patients who fail medical treatment may lead to adverse outcomes.

References

• Jain S, Ahuja V, Limdi JK. Optimal management of acute severe ulcerative colitis. Postgraduate Medical Journal 2019;95:32-40.
• Jakobovits SL, Travis SPL. Management of acute severe colitis. British Medical Bulletin, 2005;75-76:131-144.
• Infliximab for acute exacerbations of ulcerative colitis. NICE guidance.
• Updates in Inflammatory Bowel Disease, Dr. Benjamin L. Cohen discusses the management of patients with acute, severe ulcerative colitis (UC).