Fulminant Colitis

Fulminant colitis is rapidly progressive severe colonic inflammation with systemic toxicity and impending or established organ dysfunction.

Ulcerative colitis is a major cause, but severe Clostridioides difficile or other infectious colitis must be excluded.

Toxic megacolon is a possible progression of fulminant colitis but colonic dilatation is not required for fulminant disease.

Patients typically have frequent bloody stools, severe urgency, abdominal pain, fever and tachycardia.

Features associated with severe disease include more than approximately ten bloody stools daily, anaemia, rising C reactive protein, hypoalbuminaemia, abdominal distension and systemic toxicity.

Increasing distension, guarding, hypotension or decreasing stool frequency in a severely ill patient can indicate toxic megacolon or impending perforation.

Test for Clostridioides difficile at admission.

Perform limited flexible sigmoidoscopy within approximately 24 to 72 hours when safe to assess severity and obtain biopsies for cytomegalovirus where appropriate. Avoid full colonoscopy in severe disease.

Monitor stool frequency, bleeding, vital signs and serial C reactive protein rather than relying on one laboratory value.

Hospitalise and involve colorectal surgery early.

Provide venous thromboembolism prophylaxis even in the presence of inflammatory rectal bleeding unless a specific contraindication exists.

A practical regimen is:

Enoxaparin 40 mg subcutaneously once daily, with renal and weight adjustment where appropriate.

For acute severe ulcerative colitis:

Methylprednisolone 60 mg IV daily

or

Hydrocortisone 100 mg IV three to four times daily.

Assess response by approximately day 3.

Failure to respond adequately can be treated with rescue therapy in a stable patient without perforation or uncontrolled sepsis:

Infliximab 5 mg/kg IV

or

Cyclosporine approximately 2 mg/kg/day by continuous IV infusion, with therapeutic monitoring and specialist supervision.

Rescue therapy should not be used repeatedly to postpone necessary surgery.

Proceed to urgent total abdominal colectomy with end ileostomy for toxic megacolon, perforation, uncontrolled haemorrhage, progressive organ dysfunction, worsening peritonism or medical treatment failure. The rectum is usually left in place during the emergency operation, with definitive restorative surgery delayed until recovery and steroid withdrawal.