Patients with clinical evidence of actual or impending perforation should undergo urgent surgery. Level of Evidence: III; Grade of Recommendation: A
The diagnosis of severe colitis is based on the criteria of Truelove and Witts and is defined as colitis with more than six bloody stools per day, fever (temperature, >37.5 degrees Celsius [C]), tachycardia (heart rate, >90 beats per minute), anemia (hemoglobin, <75 percent of normal), and elevated sedimentation rate (ESR, >30 mm per hour). Alternatively, toxic, or fulminant, colitis is characterized by more than ten bloody stools per day, fever (temperature, >37.5 degrees C), tachycardia (heart rate, >90 beats per minute), anemia (transfusion required), elevated sedimentation rate (ESR, >30 mm per hour), colonic dilation on radiography, and abdominal distention with tenderness. When the colonic distention of the transverse colon exceeds 6 cm, the diagnosis becomes toxic megacolon. Surgery is required in 20 to 30 percent of patients with toxic colitis.
Patients with toxic colitis receiving surgical intervention before perforation have a significantly better outcome than those operated on after perforation. However, there are few "hard" signs of impending perforation in patients with toxic colitis. Perforation can occur without dilation and these patients often do not exhibit classic signs of peritonitis. Persistent or increasing colonic dilation, pneumatosis coli, worsening local peritonitis, and the development of multiple organ failure can be signs of impending or actual perforation. Localized peritonitis may reflect only local inflammation or may be a sign of impending perforation.
Patients whose condition worsens on medical therapy or who fail to make significant improvement after a period of 48 to 96 hours of appropriate medical therapy should be considered for surgery. Level of Evidence: III; Grade of Recommendation: B
Limited evidence suggests that intravenous cyclosporine is more effective than standard steroid-based treatment for severe colitis and has been advocated as a second-line agent before colectomy. The need for and timing of surgery in patients whose condition seems to "plateau" after a period of initial improvement often is difficult to judge. However, patients with more than eight stools per day or three to eight stools and a C-reactive protein > 45 mg/mL after three days of therapy have an 85 percent chance of requiring colectomy during the same hospitalization, regardless of whether corticosteroid or cyclosporine treatment is used. Furthermore, persistent colonic distention seems to characterize a subgroup of patients who respond poorly to medical therapy and are at increased risk for the development of megacolon. Prolonged observation of these patients may risk exhaustion of their physiologic reserve but does not necessarily increase perioperative morbidity.