Colitis Treatment & Management

The treatment of one cause of colitis, necrotizing enterocolitis (NEC), includes cessation of feedings, nasogastric decompression, and intravenous fluid resuscitation with attention to electrolytes and acid-base balance. Antibiotics should be started as soon as cultures are obtained. Close monitoring with cardiorespiratory support is provided as required. Exploratory laparotomy with resection of bowel and external ostomy diversion is indicated if there is failure of medical management, erythema of abdominal wall, a single fixed loop, a palpable mass, and/or evidence of perforation (eg, pneumoperitoneum, brown paracentesis). Central venous access is needed after bowel resection for total parenteral nutrition.^[4] Closely monitor the child for complications of short bowel syndrome and central catheters.

• Treatment of allergic colitis consists of elimination of the offending protein from the infant's diet. Infants should receive a formula containing casein-hydrolysate as the protein source (eg, Nutramigen, Pregestimil, Alimentum). Mothers of exclusively breastfed infants with allergic colitis should eliminate the offending proteins (typically milk) from their diets. Persistence of gross bleeding after 14 days following a formula change is an indication for proctosigmoidoscopy. Infants with response to diet change should be challenged around their first birthday. A study by Baldassarre et al found the addition of Lactobacillus rhamnosus GG (LGG) to extensively hydrolyzed casein formula (EHCF) (eg, Nutramigen) significantly improved hematochezia and fecal calprotectin compared with EHCF alone.^[40]
• Treatment of a child with pseudomembranous colitis depends on the severity of disease. Mild cases require cessation of antibiotics and supportive therapy with fluids and electrolytes. Evaluate patients with severe or persistent antibiotic-associated colitis for C difficile toxin in the stool. The patient should be treated with oral metronidazole (30 mg/kg/d in 4 divided doses) or oral vancomycin (40 mg/kg/d in 4 divided doses).
• Management of bacterial colitis is somewhat controversial. Shigellosis stands alone as the only form of bacterial colitis for which antibiotics have proved efficacious.

  • Antimicrobial therapy shortens the course of the illness and the duration of excretion of the organisms in the stool by alleviating the signs and symptoms and limiting the transmission of the disease. Trimethoprim-sulfamethoxazole (TMP-SMZ) is the initial drug of choice; fluoroquinolones and ceftriaxone are the alternatives.
  • If Salmonella bacteremia is suspected, intravenous cefotaxime (200 mg/kg/d in 4 divided doses) or ceftriaxone (100 mg/kg/d in 2 divided doses) should be initiated. Alternative treatments include chloramphenicol (100 mg/kg/d in 4 divided doses) or, in adolescents, fluoroquinolones. TMP-SMZ is the drug of choice when oral treatment is indicated.
  • In Yersinia enterocolitica, antibiotic therapy of intravenous gentamicin (5-7.5 mg/kg/d in 3 divided doses) is indicated in patients with persistent diarrhea or suspected sepsis. Alternative antibiotics may include chloramphenicol, colistin, and kanamycin.
  • Campylobacter enteritis is usually self-limited. The organism is sensitive to erythromycin and ciprofloxacin, but antibiotic treatment has not been proved to decrease the duration of diarrhea.
  • Treatment of amebic colitis includes metronidazole and iodoquinol or paromomycin.
  • Please see the eMedicine articles, Crohn Disease and Ulcerative Colitis.
• Management of inflammatory bowel disease (IBD) depends on the severity of the disease at presentation and is intended to decrease the bowel inflammation, with the goal of eventual healing, managing complications, and preventing recurrence or worsening disease.

  • The therapy includes pharmacotherapy, surgery, nutrition,^[5] supportive therapy, psychotherapy, and cancer screening.
  • Medications used to treat IBD can be classified into six categories, as follows:
    • Aminosalicylates (sulfasalazine, mesalamine)
    • Corticosteroids (prednisone, budesonide)
    • Immunomodulators (eg, azathioprine, 6-mercaptopurine)
    • Antibiotics (eg, metronidazole, ciprofloxacin)
    • Probiotics (Lactobacillus GG, Saccharomyces boulardii)
    • Biological agents (eg, infliximab)^{[6, 7]}
  • Children with mild manifestations can be treated as outpatients with arrangement for follow-up treatment with a gastroenterologist.
• The initial therapy for children with mild ulcerative colitis (UC) or Crohn disease (CD) is usually sulfasalazine, a 5-aminosalicylate drug (5-ASA) that is given alone or in combination with topical enemas (ie, corticosteroid, mesalamine) or corticosteroid foam. Adolescents may prefer the foam because of its ease of administration and reduced sensation of rectal distention and urgency.
• Patients with moderate and severe disease (fever, bloody stools, severe abdominal pains, anemia, hypoalbuminemia) require supportive treatment, often with intravenous hydration.
• Hospitalization is often indicated for management of acute disease with corticosteroids and or immunosuppressive agents.
• Intravenous methylprednisolone or hydrocortisone at a dose equivalent to 1-2 mg/kg/d of prednisone is recommended. The goal is to use steroids for a short period and change to a maintenance therapy as soon as possible.
• Maintenance therapy may require administration of 5-ASA or an immunomodulator, such as azathioprine or 6-mercaptopurine.
• Refractory patients with CD may need infliximab as a maintenance agent. Infliximab has been used in the treatment of severe CD, but experience with its use in severe UC is limited. A study from Brazil concluded that infliximab was effective in the treatment of CD and UC in children and adolescents.^[8]
• If toxic megacolon is suspected, aggressive resuscitation with fluids and electrolytes is required.
• Begin a combination of broad-spectrum intravenous antibiotics, such as ampicillin (200 mg/kg/d), gentamicin (5-7.5 mg/kg/d), and clindamycin (40 mg/kg/d). Alternate therapy may include either ampicillin/sulbactam (Unasyn) or cefoxitin in combination with gentamicin.
• Medical treatment includes adequate nutritional intake and social and emotional support.
• Nutrition therapy may be primary or adjunctive in CD but is only adjunctive in UC. Elemental or polymeric formulas may affect remission in as many as 80% of patients with CD.
• No specific therapy is indicated for Henoch-Schönlein purpura (HSP). Steroids are used to treat severe abdominal pain or arthritis in selected patients.

Surgery is indicated in UC or CD if uncontrolled GI bleeding, bowel perforation, bowel obstruction, failure to respond to medical therapy, and unacceptable medical toxicity are present.

• Total colectomy may be indicated in UC when the patient has toxic megacolon or acute fulminant colitis or in selected severe forms when medical therapy (including the newest immunosuppressive agents, eg, tacrolimus, infliximab) has failed.^[9] In UC, colectomy usually is performed with the creation of a "pouch" from the distal ileum and is curative (see Ulcerative Colitis). As many as 40% of the children may develop the so-called "pouchitis" (inflammation of the pouch) within 1 year. This entity is of unclear origin, but typically responds quickly to a course of antimicrobial treatment. Recent evidence in adults suggests that prophylaxis with probiotics may be an effective preventative tool.
• In CD, surgery is not curative because recurrent disease at the site of surgery is common. In CD, segmental bowel resection is the most common procedure and usually involves the diseased terminal ileum and adjacent inflamed colon. Stricturoplasty should be considered if there is stenosed bowel segment without active inflammation.
• At times surgical resection is used to treat growth failure.

A surgical consultation is required in patients with suspected toxic megacolon, appendicitis, intestinal obstruction, fulminant colitis, or significant GI bleeding.

See Medical Care.