Ulcerative colitis

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- fulminant colitis/toxic megacolon
- perforation
- haemorrhage

- fulminant colitis: severe form of colitis that may be complicated by toxic megacolon or perforation
- clinical criteria for severe UC:

• > 6 bowel movements/day
• bloody diarrhoea
• pyrexia
• tachycardia
• Hb < 10 g/dl
• ESR > 30
• albumin < 30 g/l

- other clinical features:

• deterioration over several weeks
• weight loss common
• tenesmus
• crampy abdominal pain
• postural changes in pulse & BP
• +/- diffuse abdo tenderness

- clinical features suggestive of toxic megacolon (+/- perforation):

• abdo guarding
• absent bowel sounds
• hypertympanism
• +/- decreased no. of bowel movements

- U&E: raised urea, hypokalaemia
- FBC: raised WCC +/- band forms
- stool cultures for bacteria, ova and parasites and assay for Clostridia toxin to exclude infectious causes
- erect CXR and left lateral decubitus AXR to look for free gas
- supine AXR: +/- loss of colonic haustra, "thumbprinting" due to bowel wall oedema, dilatation, most prominent in transverse colon
- sigmoidoscopy to confirm diagnosis and exclude pseudomembranous colitis

- should be prompt and aggressive
- fluid resuscitation
- NBM
- parenteral nutrition. NB some advocate limited enteral nutrition as long as it does not increase symptoms
- narcotic analgesics and antidiarrhoeal agents contraindicated because of theoretical risk of precipitating toxic megacolon
- surgical consultation
- systemic steroids: hydrocortisone 100mg tds/prednisolone 20mg IV tds/methylprednisolone 16 mg IV tds. Latter 2 have the advantage of causing less sodium retention and less potassium wasting
- hydrocortisone or mesalazine enemas may reduce symptoms
- antibiotics not indicated unless patient appears toxic with high fever, leucocytosis with band forms, and abdominal tenderness
- timing of surgery controversial. Some advocate surgery if there is no obvious improvement within 5-7 days while other recommend waiting 2 weeks
- subgroup of patients with severe but nontoxic colitis who continue to have frequent bloody stools with low-grade fever and bands on peripheral smear despite a week of high dose steroids who will respond to broad-spectrum antibiotics
- recent studies suggest that cyclosporin may be a useful alternative to surgery in those patients who fail to respond to steroids
- toxic megacolon: broad spectrum antibiotics (eg 3rd generation cephalosporin + metronidazole); NG tube; +/- long small bowel tube & rectal tube; lie prone for 15 mins every 2 h to aid redistribution of gas from transverse to descending colon; parenteral nutrition; surgery if there is no response to aggressive medical therapy within 24-72 h.

- potentially lethal complication (50% mortality)
- up to 1/3 of patients with toxic megacolon
- can complicate fulminant colitis without colonic dilatation

- signs of sepsis
- increasing abdo pain & guarding
- signs may be attenuated in patients who have been on systemic steroids for prolonged period, malnourished and elderly. In these patients frequent plain AXR may help
- free gas on decubitus AXR and erect CXR

- slightest sign of perforation should prompt urgent laparotomy

- severe intestinal bleeding uncommon and accounts for only 6-10% of all urgent colectomies in patients with UC
- pancolitis and toxic megacolon are risk factors
- surgery is definitive and often life-saving treatment
- all patients in whom subtotal colectomy is considered should have sigmoidoscopy first to exclude rectum as the major site of bleeding

© Charles Gomersall December 1999

©Charles Gomersall, September, 2008 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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