Fulminant Colitis

Dion Morton, Birmingham

Powerpoint File

Fulminant colitis can be considered an acute and progressive inflammatory disorder of the large bowel mucosa, which has failed to respond to escalating medical therapy, and for which surgical intervention must be considered. Ulcerative colitis is the commonest cause of this condition, but changing patterns of disease and increasing levels of intervention mean that other causes must be frequently considered. There are considerable and ongoing advances in medical therapy for this condition. By comparison the surgical treatment has changed little over the last 30 years. Optimal management requires the close collaboration between the gastroenterologist, surgeon, nutrition team and colorectal nurse specialist. The key to successful management of these patients is timely surgery before large bowel perforation and before the patient is too debilitated to withstand the surgical insult.

Epidemiology: The incidence of Crohn’s disease has risen worldwide whereas the incidence of ulcerative colitis is stable (1). The prevalence of Crohn’s disease is now comparable to that of ulcerative colitis, changing the presenting features of the acute presentation. Toxic megacolon and free perforation are not common features of fulminant Crohn’s colitis, in which local abscess formation and fistulation are a more prevalent feature. Such changes are more readily diagnosed by abdominal CT scanning, rather than plain X ray.

Aetiology: Alternative causes for fulminant colitis must be considered. There is a rising incidence of Clostridium Difficile infection in the hospital community, as a consequence of prolonged courses of treatment with broad spectrum antibiotics (2).

This problem is also seen in the immune suppressed community, such as those undergoing organ transplantation. Rarer infections such as cytomegalovirus and even Entamoeba induced colitis are increasingly reported (3).

Patients undergoing cardiac surgery present a special case, because of the use of inotropes and the use of aortic balloon pumps which both reduce an already compromised gut perfusion. In this population, ischaemic colitis is not an infrequent complication.

The need for early surgery in these chronically debilitated patients must be recognised. They are generally ill equipped to withstand prolonged periods of poor nutrition combined with intercurrent protein loss from the colon.

Surgery: The surgical treatment of choice in these patients remains a total colectomy and end ileostomy. Some groups are exploring a laparoscopic approach in selected patients (4). The risks of operative perforation in the acutely ill patient preclude this being advocated more widely at the present time. There are no studies advocating a primary restorative procedure for these patients.

Following surgery and full recovery, many of these patients will request a restorative proctocolectomy. In our own practice, at colectectomy, we advocate leaving a long rectal stump, as this makes subsequent pelvic dissection for reconstruction safer.

The outcome for reconstruction in patients with Crohn’s disease is considerably worse, and accurate pre-reconstruction diagnosis is required. Excluding a diagnosis of Crohn’s disease can be difficult in fulminant disease resulting in the less satisfactory diagnosis of indeterminant colitis (5). Careful assessment of the macroscopic and microscopic features of the colon are required to minimise this diagnosis.

Concerns about the consequences of more aggressive immunosuppression in these patients appear to be largely unfounded (6). The main medical risk factor appears to remain long term steroid therapy.

Summary: Although the surgery for fulminant colitis has changed little in recent years, the complexity of these patients has increased. More aggressive medical therapy can delay surgery in a critically ill patient, and changing patient populations have broadened the differential diagnosis. Careful monitoring of these patients by a multidisciplinary team remains central to their safe management.

References

1. Munkholm P et al. Increased incidence of Crohn’s disease in Copenhagen. Ugeskr Laeger. 1993;155:3199-202.

2. Dallal RM et al. Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg 2002 Mar;235(3):363-72.

3. Singh B et al. Fulminant amoebic colitis: a favourable outcome. Int Surg. 2001 Apr-Jun;86(2):77-81.

4. Marcello PW, Laparoscopic total colectomy for acute colitis: a case-control study.

Dis Colon Rectum. 2001 Oct;44(10):1441-5.

5. Gramlich T et al. Pathological subgroups may predict complications but not late failure after ileal pouch-anal anastomosis for indeterminate colitis.

Colorectal Dis. 2003 Jul;5(4):315-9.

6. Mahadevan U et al. Azathioprine or 6-mercaptopurine before colectomy for ulcerative colitis is not associated with increased postoperative complications.

Inflamm Bowel Dis. 2002 Sep;8(5):311-6.

Hyde GM et al. Cyclosporin for severe UC. Dis Colon Rectum 2001;44:1436-40.