Therapeutic Strategy and Timing of Medical and Surgical Management

The first priority of any therapeutic strategy for acute ulcerative colitis is to reduce or avoid morbidity and mortality. Mortality decreased dramatically from 30% to less than 5% after Truelove and Witts proposed in 1955 a three-step strategy [3]:

- Selection of patients with severe ulcerative colitis

- Intensive medical treatment, including high-dose intravenous steroids, for 5-7 days

- Colectomy for patients who fail to respond or who deteriorate

Initial investigations include abdominal examination focused on peritoneal signs (sometimes masked by previous corticosteroid therapy), complete blood count, serum profile, blood cultures, stool testing for Clostridium difficile, cytomegalovirus (CMV), Escherichia coli, salmonella, shield, amoeba, coagulation studies and plain abdominal and chest X-rays. A limited proctosigmoidoscopy with minimal insufflation can be helpful in previously undiagnosed patients to exclude pseudomembranous colitis or ischaemic colitis. However, barium enema and colonoscopy are usually contraindicated in the presence of acute fulminating colitis or toxic megacolon because overdistension may lead to colonic perforation. Endoscopic findings of deep ulcers can provide useful prognostic information, facilitating the decision to proceed with medical or urgent surgical treatment. Intravenous fluids are given to correct metabolic derangement, and blood products are administered for anaemia or coagulopathy. A central venous catheter is inserted for total parenteral nutrition (TPN); bowel rest and hyperalimentation have potential clinical advantage and should be maintained until the patient is receiving adequate enteral feedings. Nasogastric suction is used only in case of severe vomiting or gastrointestinal dilatation. In true fulminant colitis, the usual therapeutic scheme is shortened: 2-3 days of intense steroid therapy (methylprednisolone 40-60 mg/day i.v.), followed by surgery in case of resistance. Finally, patients with unresponsive toxic megacolon after 24-48 h of intensive intravenous treatment and patients with impending perforation, free perforation, generalised peritonitis, septic shock or massive rectal bleeding should be submitted to urgent or emergent surgery.

In patients in whom a satisfactory response is obtained with medical therapy, the intravenous cor-ticosteroid is reduced after 5 days and gradually switched to oral prednisolone. Maintenance therapy with purine analogues or immunosalicylates is started. If a stable patient does not respond to i.v. corti-costeroid therapy within 5-7 days, i.v. cyclosporine therapy (2 or 4 mg/kg per day i.v.), adjusted as necessary, is initiated. If cyclosporine therapy is con-traindicated because of renal insufficiency, hypocho-lesterolemia, sepsis or patients refusal, surgical treatment is advised. When colitis responds to cyclosporine treatment, maintenance therapy with mercaptopurine (6-MP) or azathioprine is considered. If colitis does not respond to cyclosporine treatment within 4-5 days or complete remission is not achieved within 10-14 days, there is indication for surgery. Infliximab, heparin and tacrolimus have been studied for management of severe colitis. The role of these medications will be better clarified through future investigations [19]. Most patients with acute, severe, fulminant colitis respond to aggressive medical therapy. Care must be taken, however, not to overtreat patients because of the side effects of immunosuppressive drugs. Patients who show no signs of improvement must be referred to surgery. The decision regarding management of fulminant ulcerative colitis requires considerable experience, especially in unstable patients who do not rapidly respond to conservative treatment [20].

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