Abstract
Fulminant colitis is an important clinical challenge despite great progress in its management over the decades. Corticosteroids greatly reduced mortality and colectomy rates, however, case fatality rates remain at roughly 2%. The goal of medical therapy is to prevent colectomy while avoiding complications that may lead to death or worsen the outcome of colectomy, if this cannot be avoided. In addition to corticosteroids, cyclosporine and infliximab have been used in the setting of severe colitis. Rescue therapy with cyclosporine must be followed by maintenance therapy with a thiopurine agent if successful remission is to be maintained durably. Rescue therapy with infliximab may be followed by maintenance therapy with the same agent, or in some cases, by a thiopurine agent. Both cyclosporine and infliximab may be associated with increased risks, such as neurotoxicity in the case of cyclosporine, or opportunistic or serious infection in the setting of immune suppression from either agent. In either case, it is critical to avoid excessive prolongation of unsuccessful medical therapy if optimal surgical outcomes are to be achieved. A great deal of judgment is needed to guide the timing of colectomy, but it is clear that mortality increases as the time to colectomy is prolonged.
Similar content being viewed by others
References
Truelove SC, Jewell DP. Intensive intravenous regimen for severe attacks of ulcerative colitis. Lancet 1974;1:1067–1070. doi:10.1016/S0140-6736(74)90552-2.
Truelove SC, Witts LJ. Cortisone in ulcerative colitis; final report on a therapeutic trial. BMJ 1955;2:1041–1048.
Cottone M, Pietrosi G, Martorana G, Casa A, Pecoraro G, Oliva L et al. Prevalence of cytomegalovirus infection in severe refractory ulcerative and Crohn’s colitis. Am J Gastroenterol 2001;96:773–775. doi:10.1111/j.1572-0241.2001.03620.x.
Carbonnel F, Lavergne A, Lemann M, Bitoun A, Valleur P, Hautefeuille P et al. Colonoscopy of acute colitis. A safe and reliable tool for assessment of severity. Dig Dis Sci 1994;39:1550–1557. doi:10.1007/BF02088063.
Alemayehu G, Jarnerot G. Colonoscopy during an attack of severe ulcerative colitis is a safe procedure and of great value in clinical decision making. Am J Gastroenterol 1991;86:187–190.
Carbonnel F, Gargouri D, Lemann M, Beaugerie L, Cattan S, Cosnes J et al. Predictive factors of outcome of intensive intravenous treatment for attacks of ulcerative colitis. Aliment Pharmacol Ther 2000;14:273–279. doi:10.1046/j.1365-2036.2000.00705.x.
Mantzaris GJ, Hatzis A, Archavlis E, Petraki K, Lazou A, Ladas S et al. The role of colonoscopy in the differential diagnosis of acute, severe hemorrhagic colitis. Endoscopy 1995;27:645–653.
Almer S, Bodemar G, Franzen L, Lindstrom E, Nystrom P, Strom M. Use of air enema radiography to assess depth of ulceration during acute attacks of ulcerative colitis. Lancet 1996;347:1731–1735. doi:10.1016/S0140-6736(96)90808-9.
Prantera C, Lorenzetti R, Cerro P, Davoli M, Brancato G, Fanucci A. The plain abdominal film accurately estimates extent of active ulcerative colitis. J Clin Gastroenterol 1991;13:231–234.
Lennard-Jones JE, Ritchie JK, Hilder W, Spicer CC. Assessment of severity in colitis: a preliminary study. Gut 1975;16:579–584. doi:10.1136/gut.16.8.579.
Rosenberg W, Ireland A, Jewell DP. High-dose methylprednisolone in the treatment of active ulcerative colitis. J Clin Gastroenterol 1990;12:40–41. doi:10.1097/00004836-199002000-00011.
Bossa F, Fiorella S, Caruso N, Accadia L, Napolitano G, Valvano MR et al. Continuous infusion versus bolus administration of steroids in severe attacks of ulcerative colitis: a randomized, double-blind trial. Am J Gastroenterol 2007;102:601–608. doi:10.1111/j.1572-0241.2006.01007.x.
Travis SP, Farrant JM, Ricketts C, Nolan DJ, Mortensen NM, Kettlewell MG et al. Predicting outcome in severe ulcerative colitis. Gut 1996;38:905–910. doi:10.1136/gut.38.6.905.
Lichtiger S, Present DH, Kornbluth A, Gelernt I, Bauer J, Galler G et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med 1994;330:1841–1845. doi:10.1056/NEJM199406303302601.
Cohen RD, Stein R, Hanauer SB. Intravenous cyclosporin in ulcerative colitis: a five-year experience. Am J Gastroenterol 1999;94:1587–1592. doi:10.1111/j.1572-0241.1999.01149.x.
Jarnerot G, Hertervig E, Friis-Liby I, Blomquist L, Karlen P, Granno C et al. Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study. Gastroenterology 2005;128:1805–1811. doi:10.1053/j.gastro.2005.03.003.
Maser EA, Deconda D, Lichtiger S, Present D, Kornbluth A. Cyclosporine and infliximab as acute salvage therapies for each other, in severe steroid refractory ulcerative colitis. Gastroenterology 2007;132:A180.
Selvasekar CR, Cima RR, Larson DW, Dozois EJ, Harrington JR, Harmsen WS et al. Effect of infliximab on short-term complications in patients undergoing operation for chronic ulcerative colitis. J Am Coll Surg 2007;204:956–962. doi:10.1016/j.jamcollsurg.2006.12.044.
Kaplan GG, McCarthy EP, Ayanian JZ, Korzenik J, Hodin R, Sands BE. Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis. Gastroenterology 2008;134:680–687.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Sands, B.E. Fulminant Colitis. J Gastrointest Surg 12, 2157–2159 (2008). https://doi.org/10.1007/s11605-008-0661-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-008-0661-1