Acute severe colitis

Acute severe colitis

Review appropriate mild or moderate algorithm

Confirm severe disease

ECCO statement 3C (UC 2017)

A full medical history should include detailed questioning about the onset of symptoms, rectal bleeding, stool consistency and frequency, urgency, tenesmus, abdominal pain, incontinence, nocturnal diarrhoea, and extra-intestinal manifestations. Recent travel, possible contact with enteric infectious illnesses, medication [including antibiotics and non-steroidal anti-inflammatory drugs], smoking habit, sexual behaviour, family history of inflammatory bowel disease or colorectal cancer, and previous appendectomy should be recorded [EL5]

ECCO statement 3D (UC 2017)

Physical examination should include pulse, blood pressure, temperature, weight and height, and abdominal examination for distension and tenderness. Perianal inspection and digital rectal examination may be performed if appropriate. Physical examination may be unremarkable in patients with mild or moderate disease [EL5]

Further information

  • Colitis-like symptoms can be caused by CMV colitis; rectal mucosal prolapse; Crohn’s disease; malignancy; IBS with haemorrhoidal bleeding

  • Ensure acute colitis is a likely diagnosis based on clinical history and examination

Consider alternative diagnoses

ECCO statement 11F (UC 2017)

Patients with bloody diarrhoea ≥ 6/day and any signs of systemic toxicity (pulse > 90 min–1, temperature > 37.8°C, haemoglobin < 105 g/l, erythrocyte sedimentation rate [ESR] > 30 mm/h, or C-reactive protein [CRP] > 30 mg/l) have severe colitis and should be admitted to hospital for intensive treatment [EL4]. Patients with comorbidities or > 60 years old have a higher risk of mortality [EL3]

Further information

  • Admit the same day, ideally to a combined medical / surgical ward

  • Notify colo-rectal surgical team and stoma-nurse; joint care if concern

  • Stop anticholinergic and antidiarrhoeal medicines, opiods and NSAIDs

  • Concurrent urgent investigation and treatment

Admit patient to hospital

Steroids contraindicated or refractory?

  • Thrombosis prophylaxis (subcutaneous LMWH)

  • IV fluids to correct and prevent dehydration (e.g. alternating Hartmann’s solution and 5% dextrose)

  • IV K+ and Mg++ dependent on serum levels (hypokalaemia common with diarrhoea and steroid therapy)

  • IV steroids and oral vitamin D unless previously steroid-refractory

  • Adjunctive topical mesalazine or steroid if tolerated

  • IV metronidazole and ciprofloxacin only if toxic dilatation or temperature > 37.8˚C, following rehydration

  • PO metronidazole if C. difficile or amoebiasis likely

  • Request dietetic review and consider enteral nutrition

  • Blood transfusion if Hb < 80-100 g/L

Urgent treatment

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

Further information

  • Stool chart (often more accurate if completed by patient); standard observations 4-6 hourly

  • Stool culture, C. difficle toxin, parasites if recent travel history

  • Same day unprepared limited flexible sigmoidoscopy , including 2 biopsies to exclude CMV

  • Supine AXR to exclude toxic megacolon (transverse colon diameter> 5.5 cm and systemic toxicity; rare in left-sided colitis) and assess extent (suggested by stool-free colon)

  • Request pre-biologic therapy investigations

  • Check FBC, U&E, Mg++, LFT, coagulation profile, Ca++ & PO43-, lipid profile, CRP or ESR, TPMT

Urgent investigations

  • In ≈5% of patients admitted with severe UC

  • Request same day experienced colorectal surgical and stoma therapist review as early colectomy likely (perforation mortality ≈50%)

  • Correct electrolytes (K+, Mg++). 24-48 hours intensive medical therapy warranted provided patient stable

Urgent surgical review

ECCO statement 11G (UC 2017)

Initial recommended treatment for severe active ulcerative colitis is intravenous steroids [EL1]. Monotherapy with intravenous ciclosporin [EL2] is an alternative especially in cases of serious adverse events due to steroids. All patients should receive adequate volume of intravenous fluids, and low-molecular-weight heparin for thromboprophylaxis; electrolyte abnormalities and anaemia should be corrected, if needed [EL5]. Patients are best cared for jointly by a gastroenterologist and a colorectal surgeon [EL5]

Further information

  • Medical review at least 12-hourly. Colo-rectal surgical team and stoma-nurse review if no improvement

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness -> senior review to assess need for emergency colectomy

  • Supine AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement)

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

  • If no clinical response, “2nd-line” therapy and discuss need for colectomy on or soon after day 3 in absence of improvement

Regular review

  • Stool frequency > 12 predicts colectomy risk of 55% without 2nd-line therapy

Predict colectomy risk

  • Failure of toxic dilation to respond to 48 hours therapy

  • Deterioration despite optimal treatment

  • Patient choice

Surgery if deterioration

ECCO statement 11G (UC 2017)

Initial recommended treatment for severe active ulcerative colitis is intravenous steroids [EL1]. Monotherapy with intravenous ciclosporin [EL2] is an alternative especially in cases of serious adverse events due to steroids. All patients should receive adequate volume of intravenous fluids, and low-molecular-weight heparin for thromboprophylaxis; electrolyte abnormalities and anaemia should be corrected, if needed [EL5]. Patients are best cared for jointly by a gastroenterologist and a colorectal surgeon [EL5]

Further information

  • Medical review at least 12-hourly. Colo-rectal surgical team and stoma-nurse review if no improvement

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness -> senior review to assess need for emergency colectomy

  • Supine AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement)

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

  • If no clinical response, “2nd-line” therapy and discuss need for colectomy on or soon after day 3 in absence of improvement

Regular review

  • 24 h stool frequency > 8, or 3-8 with CRP > 45 mg/L, then risk colectomy 85% without 2nd-line therapy
Predict colectomy risk

ECCO statement 11G (UC 2017)

Initial recommended treatment for severe active ulcerative colitis is intravenous steroids [EL1]. Monotherapy with intravenous ciclosporin [EL2] is an alternative especially in cases of serious adverse events due to steroids. All patients should receive adequate volume of intravenous fluids, and low-molecular-weight heparin for thromboprophylaxis; electrolyte abnormalities and anaemia should be corrected, if needed [EL5]. Patients are best cared for jointly by a gastroenterologist and a colorectal surgeon [EL5]

Further information

  • Medical review at least 12-hourly. Colo-rectal surgical team and stoma-nurse review if no improvement

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness -> senior review to assess need for emergency colectomy

  • Supine AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement)

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

  • If no clinical response, “2nd-line” therapy and discuss need for colectomy on or soon after day 3 in absence of improvement

Regular review

  • Medical review at least 12-hourly. Colo-rectal surgical team and stoma-nurse review if no improvement.

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness →senior review to assess need for emergency colectomy

  • Supine AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement)

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

Regular review

  • Convert to oral steroids

  • Consider stopping SC thrombosis prophylaxis (advise patient to use compression stockings for a few weeks)

  • Discharge patient; arrange review in 1 week; provide contact details in case of deterioration

Discharge

  • History and examination

  • FBC, U&E, LFT, CRP or ESR

  • Plan steroid reduction (e.g. Reduce prednisolone by 5mg each week)

  • Plan maintenance therapy

Clinic review at
Week 1 (post discharge)

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

Further information

IV steroids +/- "2nd-line therapy"

  • Optimise nutrition

  • Arrange ongoing review (e.g. initially after ≈ 2 months)

  • Continue steroid reduction, and provide maintenance therapy

Clinic review at
Week 3 (post discharge)

ECCO statement 3G (UC 2017)

Microbial testing is recommended in patients with colitis relapse. This includes testing for C. difficile and Cytomegalovirus infection [EL3]

Further information

IV steroids +/- "2nd-line therapy"

Remission at
Week 12 (post discharge)

"Second-line" therapy

"Second-line" therapy

Algorithm assumes Day 5 start to second line therapy.
If started earlier, accelerate timeline accordingly.

ECCO Statement OI 5B (UC)

No vaccines are available for prevention of P. jiroveci pneumonia. For patients on triple immunomodulators with one of these being either a calcineurin inhibitor or anti-TNF therapy, standard prophylaxis with co-trimoxazole is recommended if tolerated [EL4]. For those on double immunomodulators, prophylactic co-trimoxazole should be considered especially if one of these is a calcineurin inhibitor [EL 4].

Further information

  • Medical review at least 12-hourly. Colo-rectal surgical team and stoma-nurse review

  • Continue IV steroids

  • Start either IVI ciclosporin or IV infliximab, or surgery

  • Consider P. jiroveci prophylaxis

Start "second-line" therapy from DAY 5 OR SOONER (e.g. if steroid-refractory or no improvement)

  • Medical and surgical review at least 12-hourly

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness →senior review to assess need for emergency colectomy

  • Administer infliximab +/- thiopurine (provide patient information leaflets)

  • Supine AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement)

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

  • Taper steroids over 2-4 weeks

Infliximab

  • Decision to operate depends on disease duration and disease course including extra-intestinal manifestations; and response and side-effects of medication

Surgery

  • Medical and surgical review at least 12-hourly

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness -> senior review to assess need for emergency colectomy

  • Administer ciclosporin (provide patient information leaflet)

  • Supine AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement)

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

  • Taper steroids over 2-4 weeks

Ciclosporin

  • Medical and surgical review at least 12-hourly

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness -> senior review to assess need for emergency colectomy

  • Supine AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement)

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

Regular review

  • Medical and surgical review at least 12-hourly

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness -> senior review to assess need for emergency colectomy

  • AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement) and pre-dose ciclosporin levels

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

Regular review

  • Medical and surgical review at least 12-hourly

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness -> senior review to assess need for emergency colectomy

  • Supine AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement)

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

Regular review

  • Medical and surgical review at least 12-hourly

  • Deterioration suggested by increasing pulse/temperature, or abdominal pain or tenderness -> senior review to assess need for emergency colectomy

  • AXR (performed daily if fever, tachycardia, tenderness, dilatation on initial films, or clinical deterioration)

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR (performed daily until clinical improvement) and pre-dose ciclosporin levels

  • Continue IV fluids only if patient unable to maintain hydration orally or if electrolytes deranged

Regular review

"Continue" infliximab

  • Third-line immunosuppressive therapy should only be provided in specialist centres, ciclosporin after infliximab is to be avoided.

Surgery

Continue ciclosporin

  • Third-line immunosuppressive therapy (e.g. subsequent infliximab) should only be provided in specialist centres

  • Surgery usually indicated unless ciclosporin levels sub-therapeutic

Surgery

  • Medical and surgical review daily

  • Check FBC, U&E, Mg++, CRP or ESR daily

  • Convert to oral steroids, and plan steroid reduction (usually over 4-6 weeks)

Regular review

  • Medical and surgical review daily

  • Check FBC, U&E, Mg++, CRP or ESR daily

  • Convert to oral steroids, and plan steroid reduction (usually over 10 days)

  • Switch IV to oral ciclosporin

Regular review

ECCO Statement OI 5B (UC)

No vaccines are available for prevention of P. jiroveci pneumonia. For patients on triple immunomodulators with one of these being either a calcineurin inhibitor or anti-TNF therapy, standard prophylaxis with co-trimoxazole is recommended if tolerated [EL4]. For those on double immunomodulators, prophylactic co-trimoxazole should be considered especially if one of these is a calcineurin inhibitor [EL 4].

Further information

  • Discharge medication often comprises:

    • Prednisolone (reducing dose over time)

    • Calcium / vitamin D

    • Azathioprine

    • Trimethoprim–sulphamethoxazole 80-400 mg daily

  • Provide contact details in case of deterioration

  • Arrange review within 1 week; and azathioprine-related surveillance blood testing

Start / continue azathioprine & discharge

ECCO Statement OI 5B (UC)

No vaccines are available for prevention of P. jiroveci pneumonia. For patients on triple immunomodulators with one of these being either a calcineurin inhibitor or anti-TNF therapy, standard prophylaxis with co-trimoxazole is recommended if tolerated [EL4]. For those on double immunomodulators, prophylactic co-trimoxazole should be considered especially if one of these is a calcineurin inhibitor [EL 4].

Further information

  • Discharge medication often comprises:

    • Oral ciclosporin (specify brand, e.g. Neoral™)

    • Prednisolone (reducing dose over time)

    • Calcium / vitamin D

    • Trimethoprim–sulphamethoxazole 80-400 mg daily

  • Provide contact details in case of deterioration

  • Arrange review within 1 week

Discharge

  • History, examination

  • Check FBC, U&E, LFT, CRP or ESR

  • Optimise nutrition

  • Organise surveillance blood testing, consequent to azathioprine use

  • Provide “2-week” infliximab dose

  • Arrange further clinic review (e.g. 2 weeks)

Clinic review & infliximab at
Week 1 (post discharge)

  • History, examination including blood pressure

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR

  • Titrate ciclosporin dose to drug levels

  • Start azathioprine

  • Optimise nutrition

  • Arrange review (e.g. 2 weeks)

Clinic review at
Week 1 (post discharge)

  • History, examination

  • Check FBC, U&E, LFT, CRP or ESR

  • Optimise nutrition

  • Surveillance blood testing consequent to azathioprine use

  • Schedule "6-week" infliximab dose for 2-weeks time; consider benefit of pre-dose IFX levels

  • Arrange ongoing review (e.g. after 4 & 8 weeks)

Clinic review & infliximab at
Week 3 (post discharge)

  • Third-line immunosuppressive therapy (e.g. subsequent infliximab) should only be provided in specialist centres

  • Surgery usually indicated unless ciclosporin levels sub-therapeutic

Surgery if relapse

  • History, examination including blood pressure

  • Check FBC, U&E, Mg++, LFT, Ca++ & PO43-, CRP or ESR

  • Titrate ciclosporin dose to drug levels

  • Optimise nutrition

  • Blood testing optimizing azathioprine dose

  • Arrange ongoing review (initially every 2-4 weeks)

Clinic review at
Week 3 (post discharge)

  • History, examination including blood pressure

  • Check FBC, U&E, LFT, CRP or ESR

  • Surveillance blood testing consequent to azathioprine use

Remission at
Week 12 (post discharge)

  • History, examination including blood pressure

  • FBC, U&E, LFT, CRP or ESR

  • Surveillance blood testing consequent to azathioprine use

  • Taper ciclosporin over next 2 weeks

Remission at
Week 12 (post discharge)

Terms and conditions

By using this site you acknowledge that the content of this website is based on a review process of the ECCO Consensus Guidelines and primarily aims at facilitating their visualization.

Any treatment decisions are a matter for individual clinicians and may not be based primarily on the e-Guide content.

The European Crohn's and Colitis Organisation and/or any of its staff members and/or any website contributor may not be held liable for any information published in good faith on this website.

You agree that the use of this website is at your own risk and hereby waive any and all potential claims against European Crohn's and Colitis Organisation, and/or any of its staff members and/or any of the website contributors.