Journal of Gastrointestinal Surgery

, Volume 12, Issue 12, pp 2157–2159 | Cite as

Fulminant Colitis

2008 ssat other


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.


Fulminant colitis Inflammatory bowel disease Crohn’s disease Infliximab Ulcerative colitis 


  1. 1.
    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.PubMedCrossRefGoogle Scholar
  2. 2.
    Truelove SC, Witts LJ. Cortisone in ulcerative colitis; final report on a therapeutic trial. BMJ 1955;2:1041–1048.PubMedGoogle Scholar
  3. 3.
    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.PubMedCrossRefGoogle Scholar
  4. 4.
    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.PubMedCrossRefGoogle Scholar
  5. 5.
    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.PubMedGoogle Scholar
  6. 6.
    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.PubMedCrossRefGoogle Scholar
  7. 7.
    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.PubMedCrossRefGoogle Scholar
  8. 8.
    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.PubMedCrossRefGoogle Scholar
  9. 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.PubMedCrossRefGoogle Scholar
  10. 10.
    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.PubMedCrossRefGoogle Scholar
  11. 11.
    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.PubMedCrossRefGoogle Scholar
  12. 12.
    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.PubMedCrossRefGoogle Scholar
  13. 13.
    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.PubMedCrossRefGoogle Scholar
  14. 14.
    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.PubMedCrossRefGoogle Scholar
  15. 15.
    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.PubMedCrossRefGoogle Scholar
  16. 16.
    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.PubMedCrossRefGoogle Scholar
  17. 17.
    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.Google Scholar
  18. 18.
    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.PubMedCrossRefGoogle Scholar
  19. 19.
    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.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2008

Authors and Affiliations

  1. 1.MGH Crohn’s and Colitis Center and Gastrointestinal Unit, Massachusetts General HospitalHarvard Medical SchoolBostonUSA

Personalised recommendations