[Management of severe acute colitis]

Severe acute colitis remains a challenge at every stage of its management. Once the diagnosis of acute colitis has been made, its severity is assessed according to the clinical and pathologic criteria of Truelove and Witt, in particular by morphologic and endoscopic criteria. Their recent descriptions may be used for prognostic evaluation and to guide therapeutic decision-making. In any case, the severe and complicated forms of acute colitis (perforation, massive hemorrhage, toxic megacolon) demand surgical intervention. In less severe cases, it is important to determine specific etiologies which may respond to medical therapy (primarily infections causes). The most frequent etiology by far is Inflammatory Bowel Disease (Crohn's Disease or Ulcerative Colitis); it is not always possible to make the distinction between these two entities. The first line of medical therapy for IBD is intravenous corticosteroids (1 mg/Kg) shifting over to an equivalent oral dose promptly if there has been a good response. If corticosteroids are ineffective, the second line of treatment is Cyclosporin (2 mg/Kg); this requires specific precautions and surveillance. If neither of these therapies is effective, surgical resection is indicated. Subtotal colectomy with proximal ileostomy and rectosigmoid mucous fistula is the best interventional choice to minimize septic complications and it does not limit the possibilities for a later stage reestablishment of intestinal continuity.