The initial management of toxic ulcerative colitis should include:

A. Broad-spectrum antibiotics.

C. Intravenous fluid and electrolyte resuscitation.

DISCUSSION: Toxic colitis is a potentially life-threatening complication of chronic ulcerative colitis. Typically it manifests clinically with the onset of abdominal pain and severe diarrhea, followed by abdominal distention and generalized tenderness. Once megacolon and toxicity develop, fever, leukocytosis, pallor, tachycardia, lethargy, and shock set in. The initial treatment for toxic megacolon thus includes intravenous fluid and electrolyte resuscitation, nasogastric suction, broad-spectrum antibiotics to provide anaerobic and aerobic gram-negative coverage, and total parenteral nutrition to improve nutritional status. Large intravenous doses of corticosteroids are generally administered to treat the colitis. In addition, many patients with toxic megacolon are already receiving steroid therapy and, so, need stress doses of steroids to prevent adrenal crisis. The immunosuppressive drugs 6-mercaptopurine and azathioprine may play a role in the management of refractory ulcerative colitis; however, these drugs are not indicated in the acute management of toxicity. Cyclosporine was shown to be effective in treating acute refractory ulcerative colitis in a single controlled trial, but this has not yet been confirmed by other prospective studies, and it remains a potentially dangerous drug. Opioid antidiarrheals should be avoided since they may exacerbate the colonic dilatation and increase the possibility of perforation. Limited proctoscopy may be helpful in determining the cause of the attack, but colonoscopy may be dangerous and is contraindicated in the face of acute toxic megacolon. If toxic colitis, with or without megacolon, does not improve within 48 hours, emergency surgery is warranted.