Colitis Treatment & Management

The treatment of one cause of colitis, necrotizing enterocolitis (NEC), includes cessation of feedings, nasogastric decompression, and intravenous (IV) 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. Surgical therapy (see below) is initiated if medical therapy fails.

Treatment of allergic colitis primarily involves dietary measures (see below).

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/day in 4 divided doses) or oral vancomycin (40 mg/kg/day 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, IV cefotaxime (200 mg/kg/day in 4 divided doses) or ceftriaxone (100 mg/kg/day in 2 divided doses) should be initiated. Alternative treatments include chloramphenicol (100 mg/kg/day in 4 divided doses) or, in adolescents, fluoroquinolones. TMP-SMZ is the drug of choice when oral treatment is indicated.

If Yersinia enterocolitica infection is likely, antibiotic therapy with IV gentamicin (5-7.5 mg/kg/day 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.

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 achieving eventual healing, managing complications, and preventing recurrence or worsening disease.^[6] Therapy includes pharmacotherapy, surgery (see below), nutrition (see below),^[7] supportive therapy, psychotherapy, and cancer screening. (See Crohn Disease and Ulcerative Colitis.)

Medications used to treat IBD can be classified into 6 categories, as follows:

• Aminosalicylates (eg, sulfasalazine and mesalamine)
• Corticosteroids (eg, prednisone and budesonide)
• Immunomodulators (eg, azathioprine, 6-mercaptopurine [6-MP])^[8]
• Antibiotics (eg, metronidazole and ciprofloxacin)
• Probiotics (eg, Lactobacillus GG and Saccharomyces boulardii)^[9]
• Biologic agents (eg, infliximab)^{[10, 11]}

Children with mild manifestations can be treated as outpatients, with arrangements made for follow-up treatment with a gastroenterologist.^{[12, 13, 14]}

The initial therapy for children with mild ulcerative colitis (UC) or Crohn disease (CD) is usually sulfasalazine, a 5-aminosalicylate (5-ASA) drug that is given alone or in combination with topical enemas (eg, corticosteroid or mesalamine) or corticosteroid foam. Adolescents may prefer the foam because of its ease of administration and the reduced sensation of rectal distention and urgency.

Patients with moderate and severe disease (eg, fever, bloody stools, severe abdominal pains, anemia, or hypoalbuminemia) require supportive treatment, often with IV hydration. Hospitalization is often indicated for management of acute disease with corticosteroids or immunosuppressive agents.

IV methylprednisolone or hydrocortisone at a dosage equivalent to 1-2 mg/kg/day of prednisone is recommended. The goal is to use steroids for a short period and then switch to maintenance therapy as soon as possible. Maintenance therapy may require administration of 5-ASA or an immunomodulator, such as azathioprine or 6-MP.

Patients with refractory 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.^[15]

If toxic megacolon is suspected, aggressive resuscitation with fluids and electrolytes is required. A surgical consultation is required in patients with suspected toxic megacolon, appendicitis, intestinal obstruction, fulminant colitis, or significant GI bleeding.

Begin a combination of broad-spectrum IV antibiotics, such as ampicillin (200 mg/kg/day), gentamicin (5-7.5 mg/kg/day), and clindamycin (40 mg/kg/day). Alternate therapy may include either ampicillin-sulbactam or cefoxitin in combination with gentamicin.

No specific therapy is indicated for Henoch-Schönlein purpura (HSP). Steroids are used to treat severe abdominal pain or arthritis in selected patients.

Treatment of allergic colitis consists of eliminating the offending protein from the infant’s diet. Infants should receive a formula containing casein-hydrolysate as the protein source. 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 after a formula change is an indication for proctosigmoidoscopy. Infants who respond to diet change should be challenged around their first birthday.

A study by Baldassarre et al found that the addition of Lactobacillus rhamnosus GG (LGG) to extensively hydrolyzed casein formula (EHCF) significantly improved hematochezia and fecal calprotectin in comparison with the results noted with EHCF alone.^[16]

Medical treatment of IBD 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 effect remission in as many as 80% of patients with CD.

In patients with NEC, exploratory laparotomy with resection of bowel and external ostomy diversion is indicated if there is failure of medical management, erythema of the abdominal wall, a single fixed loop, a palpable mass, or evidence of perforation (eg, pneumoperitoneum or brown paracentesis). Central venous access is needed after bowel resection to permit total parenteral nutrition.^[17] Closely monitor the child for complications of short bowel syndrome and central catheters.

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

Total colectomy may be indicated to treat UC when the patient has toxic megacolon or acute fulminant colitis or in selected severe forms of the disease for which medical therapy (including newer immunosuppressive agents such as tacrolimus and infliximab) has failed.^{[18, 19]}

In UC, colectomy usually involves the creation of a pouch from the distal ileum and typically is curative (see Ulcerative Colitis). As many as 40% of the children may develop 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. Evidence from studies of 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. Segmental bowel resection is the most common procedure for treating CD and usually involves the diseased terminal ileum and adjacent inflamed colon. Strictureplasty should be considered if there is stenosed bowel segment without active inflammation.

At times, surgical resection is used to treat growth failure.