Fulminant colitis represents transmural extension of inflammation to the serosa and is manifested by abdominal tenderness in addition to systemic toxicity. Fulminant colitis with acute abdomen occurs in approximately 10% of patients with ulcerative colitis . A definition of fulminant colitis is not equally accepted and lacks uniformity. To date, severity of the disease is based upon a composite of clinical and endoscopic criteria but no single system has been accepted. Truelove and Witts  criteria remain the most commonly used estimate of severity of the disease in clinical practice. According to this criteria, fulminant colitis is suspected when there is more than 10 stools per day, continuous rectal bleeding, anaemia requiring transfusion, temperature above 37.5 °C, pulse rate >90 min, erythrocyte sedimentation rate >30, dilated colon on X-ray and distended abdomen with decreased bowel sounds and rebound tenderness. Travis et al.  proposed a much more simplified predictor of the probable need for surgical treatment based on stool frequency and elevated C-reactive protein. One authority considers a patient to have fulminant colitis when evidence of at least two of the following exists: tachycardia, fever, leukocytosis greater than 10 500 cells/mm and hypoalbumine-mia . The advent of toxic colitis must be recognised before progression to toxic megacolon. Once the diagnosis of fulminant colitis is established, prompt aggressive medical management with intravenous steroids, antibiotics, decompressive manoeuvres (colonoscopic, patient positioning, etc.) and other supportive measures should be started. Frequent bedside and laboratory assessments together with radiologic evaluation for signs of early loss of small and large-bowel tone are mandatory. An experienced gastroenterologist and surgeon should closely monitor the patient in an intensive care unit. If there are no signs of substantial improvement within 7-10 days at most, or any signs of deterioration and threatening complications at any earlier point in the course, the patient should be offered a trial of intravenous cyclosporine or operated on immediately . If there is no response to intravenous cyclosporine within 7 days or deterioration at any time during medical therapy, urgent colectomy should be performed. There is universal consensus that fulminant colitis unresponsive to medical therapy should be treated with urgent colectomy. The difficulty is that there is considerable disagreement about the definition of "unresponsive" thus making the decision for surgical treatment and especially timing for surgery unclear. An operative specimen from a patient suffering from fulminant colitis is presented in Figure 2.
Intensive medical therapy with high-dose intravenous steroids and intravenous cyclosporine for those patients whose disease proves refractory to intravenous steroids, can spare colectomy in more than 80% of patients with no serious drug-related toxicity [10, 11, 12, 13]. Anti-tumour necrosis factor alpha (infliximab) was used in the treatment of severe ulcerative colitis with satisfactory results [14, 15] but with severe toxicity and it is generally believed that off label use of infliximab in ulcerative colitis should be avoided until efficacy is proven in randomised controlled trials . Despite satisfactory results with aggressive medical therapy, and the fact that more than half of the patients retain their colons over the long term, stubborn insistence on medical treatment and the delay of surgery can be very hazardous. Surgery should not be indefinitely delayed, as it is a very effective treatment with acceptable mortality and morbidity rates. There is growing and encouraging experience with laparo-scopic total colectomies in acute settings. Laparo-scopic colectomy allows for earlier hospital discharge, facilitates subsequent pelvic pouch construction and provides an excellent alternative to conventional surgical treatment [17, 18]. It should be stressed again that an experienced surgeon, gastroenterologist, endoscopist and radiologist should
Fig. 3. Diagnosis and management of fulminant colitis
Fig. 3. Diagnosis and management of fulminant colitis frequently monitor the patient and prompt surgical treatment in cases refractory to medical treatment before serious life-threatening complications occur. Their priorities must focus less on saving colons than on saving lives . Management of fulminant colitis is presented in Figure 3.
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