Fulminant Colitis: When the Colon Turns Toxic

Inflammatory bowel disease (IBD) is a multifactorial disease characterized by inflammation in the bowel wall. The inflammatory process, which varies in severity from person to person, can produce a variety of symptoms in the intestines and throughout the body. 

Diagram of a human colon
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Ulcerative colitis is categorized by the severity of symptoms. Categorization also helps patients and physicians anticipate the outcomes of certain treatments, and it may help identify patients who are unlikely to respond to medical therapy and would likely benefit from surgery.

Every year, about 10 to 12 new cases of ulcerative colitis are diagnosed in 100,000 people. The majority of these cases are mild or severe. However, 5% to 8% have fulminant colitis, also called acute severe colitis (acute meaning it occurs suddenly).

The signs and symptoms of fulminant colitis include:

  • More than 10 stools per day
  • Daily continuous bleeding
  • Need for blood transfusions
  • Abdominal pain and cramping
  • Elevated inflammatory markers in the blood
  • Increased heart rate (more than 90 beats per minute)

Unless the inflammation is brought under control, patients with fulminant colitis are at risk of developing toxic megacolon, the most extreme form of colitis.

In toxic megacolon, an aggressive inflammatory process paralyzes the muscular walls of the colon causing it to distend. This increases the risk that the colon will perforate (split) and spill the contents of the bowel into the abdominal cavity. This is a life-threatening situation.

How Inflammation Affects the Body

To capture the impact of fulminant colitis, it’s necessary to understand how inflammation affects the body. When inflammation in the colon is present over time or is aggressive and severe, it disrupts the integrity of tissues and cells. When these tissues and cells malfunction, the result can be cramps, frequent loose stools, bleeding, or distention. 

Since inflammation in any organ impacts the entire body, patients with colitis may also experience loss of appetite, fatigue, body aches, inability to concentrate, malnutrition, weight loss, difficulty healing, weakness, and, in the worst cases, failure to thrive. Of course, the severity of symptoms will correspond to the severity of the inflammation and the individual’s capacity to tolerate the stress. 

When inflammation is present, the body directs its resources toward supporting the immune system and fighting the source. This is where the liver comes in. In addition to utilizing nutrients from food to manufacture the proteins and glucose the body needs to survive, function, grow, and heal, the liver also uses nutritional components to build up our immune system.

In the presence of inflammation, the liver starts breaking down proteins in order to obtain certain components needed to fight the inflammation. These are called inflammatory mediators. In the presence of constant severe inflammation, the liver uses more and more of these internal protein stores.

If the inflammation is not stopped, the process spins out of control and the increase in inflammatory mediators now harms the body rather than protects it. This type of severe inflammation is termed “toxic.”

Stopping the Inflammation

A combination of clinical, biochemical, endoscopic, and radiographic criteria is used to confirm the diagnosis of ulcerative colitis, determine its severity, and rule out other infectious causes of colon inflammation, such as a bacterial or viral infection or poor blood flow.

Once the diagnosis has been confirmed, intravenous (IV) steroid therapy is started to halt the inflammatory process in hopes of returning the colon to normal function. Resolving the inflammation will stop the symptoms and prevent the downward spiral toward colon failure. Newer guidelines recommend lower doses of intravenous steroids than in the past, as these doses appear to be just as effective but with fewer side effects.

However, up to 40% of patients—mostly those with fulminant colitis or toxic megacolon—will still require urgent or emergent surgery due to massive hemorrhage or colon perforation, or because medical therapy fails to control the disease.

Determining a Treatment Strategy

Daily examinations and blood tests for inflammatory markers conducted while patients are receiving immunosuppressive treatment can enable physicians to predict the response to medical therapy.

If a person has not improved after receiving IV steroids for three to five days, current guidelines recommend starting either Remicade (infliximab) or cyclosporine (Sandimmune, Neoral, or Gengraf). The use of either of these medications was associated with a reduced need for surgery (colectomy) over the following 90 days.

If no response is seen—for example, if a person is still passing multiple bloody stools, exhibiting a fever, and is showing abdominal distension and increased heart rate—medical therapy has likely failed and surgery is necessary. At this point, colorectal surgeons will be consulted to discuss surgical options.

Although many people hope to avoid surgery, continuing to use these medications with no improvement increases the risk of side effects without benefits. Furthermore, if inflammation does not respond in a timely manner, a person may be at risk of serious complications, including toxic megacolon.

Surgery for Fulminant Colitis

Surgery for fulminant colitis involves removing the colon and rectum to eliminate the source of toxic inflammation. The majority of patients are candidates for the J-pouch (also called ileal pouch) procedure, which allows them to keep their gastrointestinal continuity and use the normal route to eliminate waste from the body.

The procedure is usually done in three steps:

  1. The colon is removed and the patient is given a temporary ileostomy. This is a hole in the abdomen through which stool empties into an external bag. With the major source of inflammation gone, the body begins to heal and the patient is able to build up nutritional reserves.
  2. After six to 12 months, the rectum is removed and the J-pouch procedure is performed. In this innovative procedure, the last portion of the small bowel is folded back on itself to create a J-shaped reservoir that stores and passes stool. The temporary ileostomy is left in place until the pouch heals.
  3. Two or three months later, the ileostomy is closed and the healthy bowel is reconnected to the anus. In some cases, this can be done as a two-stage procedure.
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  1. Feuerstein JD, Isaacs KL, Schneider Y, et al. AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis. Gastroenterology. 2020;158(5):1450-1461. doi:10.1053/j.gastro.2020.01.006

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