Inpatient Management of Acute Severe Ulcerative Colitis
Acute severe ulcerative colitis (ASUC) is a potentially life-threatening presentation of ulcerative colitis that in nearly all cases requires inpatient management and coordinated care from hospitalists, gastroenterologists, and surgeons. Even with ideal care, a substantial proportion of patients will ultimately require colectomy, but most patients can avoid surgery with intravenous corticosteroid treatment and if needed, appropriate rescue therapy with infliximab or cyclosporine. In-hospital management requires not only therapies to reduce the inflammation at the heart of the disease process, but also to avoid complications of the disease and its treatment. Care for ASUC must be anticipatory, with patient education and evaluation starting at the time of admission in advance of the possible need for urgent medical or surgical rescue therapy. Here we outline a general approach to the treatment of patients hospitalized with ASUC, highlighting the common pitfalls and critical points in management.
© 2019 Society of Hospital Medicine
Unnecessary or Potentially Harmful Medications
Several medications have the potential for misuse in patients hospitalized with UC.
Antimotility Agents
Loperamide, diphenoxylate, and opiate antidiarrheals should not be used as they may provoke toxic megacolon.42 Similarly, drugs with antimotility side effects (eg, anticholinergics) should be avoided.
Opiates
In addition to their undesirable antimotility effect, the use of opiates has been associated with poor outcomes among inpatients and outpatients with IBD, including increased morbidity and mortality.43,44 Pain severe enough to require opiates should raise suspicion for toxic megacolon, perforation, or a noninflammatory etiology. If opiates are utilized, they should be ordered as one-time doses and the patient should be reassessed for each dose.
Nonsteroidal Anti-inflammatory Drugs
These drugs, which include oral NSAIDs, intravenous ketorolac, and topic diclofenac gels, may increase disease activity in inflammatory bowel disease and should be avoided.17
5-aminosalicylates (5-ASA)
A small proportion of patients experience a paradoxical worsening of diarrhea due to the use of 5-ASA agents such as mesalamine. It is reasonable to discontinue or avoid the use of 5-ASA agents in hospitalized patients, especially as there is little to no benefit from combining a 5-ASA with a biologic or immunosuppressive drug.45
Antibiotics
There is no role for the routine use of antibiotics in patients hospitalized with ASUC. 23,46,47 Inappropriate use of antibiotics raises the risk of C. difficile infection and antibiotic resistance. However, in cases of suspected toxic megacolon or perforation, antibiotics should be administered. In situations in which a patient is treated with triple immunosuppression (ie, steroids plus two other agents, cyclosporine and mercaptopurine) antibiotic prophylaxis for Pneumocystis jiroveci is advisable.48 Using a large insurance database, Long et al. reported a low absolute incidence of Pneumocystis jiroveci in IBD patients but noted that the risk in patients with IBD was still significantly higher than matched controls. While it can be considered, we typically refrain from using prophylaxis in patients on double immunosuppression (for example, steroids plus infliximab) due to the potential adverse effects of antibiotics in this population, though many advocate using prophylaxis for all patients on cyclosporine even if this is only double immunosuppressive therapy.23
Surgical Consultation
Involving a surgeon early in an ASUC patient’s care—before needing urgent colectomy—is critical. As part of the consultation, a surgeon experienced in IBD should meet with patients to discuss multistage colectomy with ileostomy and potential future J-pouch (ileal pouch-anal anastomosis) formation. Patients should be given ample opportunity to ask questions before surgery may become urgent. Also, patients should be counseled on realistic expectations of ostomy and pouch function and, ideally, meet with an ostomy nurse.23
At some centers, surgical consultation is requested on the first hospital day, but this can result in consultations for patients who ultimately respond to intravenous steroids. Therefore, some centers advocate for surgical consultation only after a patient has failed treatment with intravenous steroids (ie, day three to four) when the risk of needing surgical management increases.23
