Surgery for Fulminant Colitis



Fulminant colitis can be considered as 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 (UC) remains 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 which are influencing the decision to proceed to surgery. By comparison, the surgical treatment itself has changed little over the last 30 years. Optimal management requires a multidisciplinary approach with 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. This chapter will cover the recent changes in fulminant colitis and its management.


Ulcerative Colitis Clostridium Difficile Infection Ischemic Colitis Stool Frequency Subtotal Colectomy 


  1. 1.
    Truelove SC, Witts LJ. Cortisone in ulcerative colitis; final report on a therapeutic trial. Br Med J. 1955;2(4947):1041–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Jones JH, Chapman M. Definition of megacolon in colitis. Gut. 1969;10(7):562–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Latella G, Vernia P, Viscido A, Frieri G, Cadau G, Cocco A, et al. GI distension in severe ulcerative colitis. Am J Gastroenterol. 2002;97(5):1169–75.PubMedCrossRefGoogle Scholar
  4. 4.
    Gore RM, Balthazar EJ, Ghahremani GG, Miller FH. CT features of ulcerative colitis and Crohn’s disease. AJR Am J Roentgenol. 1996;167(1):3–15.PubMedGoogle Scholar
  5. 5.
    Ahualli J. The target sign: bowel wall. Radiology. 2005;234(2):549–50.PubMedCrossRefGoogle Scholar
  6. 6.
    Carbonnel F, Gargouri D, Lemann M, Beaugerie L, Cattan S, Cosnes J, et al. Predictive factors of outcome of intensive intravenous treatment for attacks of ulcerative colitis. Aliment Pharmacol Ther. 2000;14(3):273–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Arnell TD. Surgical management of acute colitis and toxic megacolon. Clin Colon Rectal Surg. 2004;17(1):71–4.PubMedCrossRefGoogle Scholar
  8. 8.
    Travis SP, Farrant JM, Ricketts C, Nolan DJ, Mortensen NM, Kettlewell MG, et al. Predicting outcome in severe ulcerative colitis. Gut. 1996;38(6):905–10.PubMedCrossRefGoogle Scholar
  9. 9.
    Cacheux W, Seksik P, Lemann M, Marteau P, Nion-Larmurier I, Afchain P, et al. Predictive factors of response to cyclosporine in steroid-refractory ulcerative colitis. Am J Gastroenterol. 2008;103(3):637–42.PubMedCrossRefGoogle Scholar
  10. 10.
    Lennard-Jones JE, Ritchie JK, Hilder W, Spicer CC. Assessment of severity in colitis: a preliminary study. Gut. 1975;16(8):579–84.PubMedCrossRefGoogle Scholar
  11. 11.
    Munkholm P, Langholz E, Nielsen OH, Kreiner S, Binder V. Increased incidence of Crohn’s disease in the county of Copenhagen. Ugeskr Laeger. 1993;155(40):3199–202.PubMedGoogle Scholar
  12. 12.
    Lamontagne F, Labbe AC, Haeck O, Lesur O, Lalancette M, Patino C, et al. Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain. Ann Surg. 2007;245(2):267–72.PubMedCrossRefGoogle Scholar
  13. 13.
    Johnson S. Recurrent Clostridium difficile infection: a review of risk factors, treatments, and outcomes. J Infect. 2009;58(6):403–10.PubMedCrossRefGoogle Scholar
  14. 14.
    Zahariadis G, Connon JJ, Fong IW. Fulminant Clostridium difficile colitis without diarrhea: lack of emphasis in diagnostic guidelines. Am J Gastroenterol. 2002;97(11):2929–30.PubMedCrossRefGoogle Scholar
  15. 15.
    Greenstein AJ, Byrn JC, Zhang LP, Swedish KA, Jahn AE, Divino CM. Risk factors for the development of fulminant Clostridium difficile colitis. Surgery. 2008;143(5):623–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Jaber MR, Olafsson S, Fung WL, Reeves ME. Clinical review of the management of fulminant Clostridium difficile infection. Am J Gastroenterol. 2008;103(12):3195–203; quiz 204.PubMedCrossRefGoogle Scholar
  17. 17.
    Koss K, Clark MA, Sanders DS, Morton D, Keighley MR, Goh J. The outcome of surgery in fulminant Clostridium difficile colitis. Colorectal Dis. 2006;8(2):149–54.PubMedCrossRefGoogle Scholar
  18. 18.
    Montoro MA, Brandt LJ, Santolaria S, Gomollon F, Puertolas BS, Vera J, et al. Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study). Scand J Gastroenterol. 2011;46(2):236–46.PubMedCrossRefGoogle Scholar
  19. 19.
    Carter MJ, Lobo AJ, Travis SP. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2004;53 Suppl 5:V1–16.PubMedCrossRefGoogle Scholar
  20. 20.
    Turner D, Walsh CM, Steinhart AH, Griffiths AM. Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a meta-regression. Clin Gastroenterol Hepatol. 2007;5(1):103–10.PubMedCrossRefGoogle Scholar
  21. 21.
    Ng SC, Kamm MA. Therapeutic strategies for the management of ulcerative colitis. Inflamm Bowel Dis. 2009;15(6):935–50.PubMedCrossRefGoogle Scholar
  22. 22.
    Lichtiger S, Present DH, Kornbluth A, Gelernt I, Bauer J, Galler G, et al. Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med. 1994;330(26):1841–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Van Assche G, D’Haens G, Noman M, Vermeire S, Hiele M, Asnong K, et al. Randomized, double-blind comparison of 4 mg/kg versus 2 mg/kg intravenous cyclosporine in severe ulcerative colitis. Gastroenterology. 2003;125(4):1025–31.PubMedCrossRefGoogle Scholar
  24. 24.
    Gisbert JP, Gonzalez-Lama Y, Mate J. Systematic review: infliximab therapy in ulcerative colitis. Aliment Pharmacol Ther. 2007;25(1):19–37.PubMedCrossRefGoogle Scholar
  25. 25.
    Jarnerot G, Hertervig E, Friis-Liby I, Blomquist L, Karlen P, Granno C, et al. Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study. Gastroenterology. 2005;128(7):1805–11.PubMedCrossRefGoogle Scholar
  26. 26.
    Aratari A, Papi C, Clemente V, Moretti A, Luchetti R, Koch M, et al. Colectomy rate in acute severe ulcerative colitis in the infliximab era. Dig Liver Dis. 2008;40(10):821–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Maser EA, Deconda D, Lichtiger S, Ullman T, Present DH, Kornbluth A. Cyclosporine and infliximab as rescue therapy for each other in patients with steroid-refractory ulcerative colitis. Clin Gastroenterol Hepatol. 2008;6(10):1112–6.PubMedCrossRefGoogle Scholar
  28. 28.
    Goligher JC, de Dombal FT, Graham NG, Watkinson G. Early surgery in the management of severe ulcerative colitis. Br Med J. 1967;3(5559):193–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Kaplan GG, McCarthy EP, Ayanian JZ, Korzenik J, Hodin R, Sands BE. Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis. Gastroenterology. 2008;134(3):680–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Cima RR. Timing and indications for colectomy in chronic ulcerative colitis: surgical consideration. Dig Dis. 2010;28(3):501–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Marcello PW, Milsom JW, Wong SK, Brady K, Goormastic M, Fazio VW. Laparoscopic total colectomy for acute colitis: a case-control study. Dis Colon Rectum. 2001;44(10):1441–5.PubMedCrossRefGoogle Scholar
  32. 32.
    Bell RL, Seymour NE. Laparoscopic treatment of fulminant ulcerative colitis. Surg Endosc. 2002;16(12):1778–82.PubMedCrossRefGoogle Scholar
  33. 33.
    Bohm G, O’Dwyer ST. The fate of the rectal stump after subtotal colectomy for ulcerative colitis. Int J Colorectal Dis. 2007;22(3):277–82.PubMedCrossRefGoogle Scholar
  34. 34.
    Subramanian V, Saxena S, Kang JY, Pollok RC. Preoperative steroid use and risk of postoperative complications in patients with inflammatory bowel disease undergoing abdominal surgery. Am J Gastroenterol. 2008;103(9):2373–81.PubMedCrossRefGoogle Scholar
  35. 35.
    Holubar SD, Cima RR, Pemberton JH. Does infliximab increase complications after surgery for inflammatory bowel disease? F1000 Med Rep. 2009;1:10.Google Scholar
  36. 36.
    Subramanian V, Pollok RC, Kang JY, Kumar D. Systematic review of postoperative complications in patients with inflammatory bowel disease treated with immunomodulators. Br J Surg. 2006;93(7):793–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

  1. 1.Department of Colorectal SurgeryQueen Elizabeth HospitalBirminghamUK
  2. 2.Department of SurgeryThe Chinese University of Hong Kong, Prince of Wales HospitalHong KongChina
  3. 3.Academic Department of SurgeryQueen Elizabeth HospitalBirminghamUK

Personalised recommendations