Acute Severe Colitis: The Need for Joint Management between Gastroenterologists and Surgeons

Abstract

The management of hospitalized patients with acute, severe ulcerative colitis involves close coordination among a multidisciplinary team. For patients not improving on intravenous corticosteroids, surgical consultation should be sought. The remaining hospital course requires frequent communications between the gastroenterologist managing the medical aspects of care, and the colorectal surgeon involved in planning for potential surgery, to optimize patient outcomes. This comanagement includes joint decision-making around the timing of surgery, minimizing medications associated with postoperative morbidity, addressing nutritional and psychosocial aspects of the patient's condition, and planning for a coordinated postoperative course. In this review, we highlight these aspects of care and the need for coordination and communication between gastroenterologists and surgeons in the management of acute severe colitis.

Ulcerative colitis (UC) is a chronic inflammatory disease affecting the large bowel. Symptoms include blood-stained diarrhea, urgency, and tenesmus accompanied by abdominal pain. Acute severe UC (ASUC) occurs in approximately 15% of UC patients and usually requires hospitalization and inpatient treatment. ¹ About 20% of ASUC patients undergo surgery during the same admission, ^{2 3} and despite improved quality standards, there remains a 1% risk of mortality. ⁴

Optimal management of any UC patient involves a multidisciplinary team approach including colorectal surgeons, gastroenterologists, radiologists, pathologists, nutritionists, and enterostomal therapists. ⁵ Given the high rate of colectomy in the hospitalized ASUC patient, there is a critical need for a collaborative approach between two key consultants of the inflammatory bowel disease (IBD) multidisciplinary team: gastroenterologist and colorectal surgeon. Quite simply, colorectal surgeons should be cognizant of the gastroenterologist's management recommendations, and the gastroenterologist should be aware of concerns of the colorectal surgeon. The two should communicate freely and frequently with mutual respect for the others' expertise to optimize patient outcomes. The aim of this review is to provide an overview of the ways in which the gastroenterologist and colorectal surgeon comanage hospitalized patients with ASUC.

Initial Evaluation

The initial treatment of ASUC aims to achieve clinical remission medically, and, if this fails, to proceed to timely and appropriate surgery which can be life-saving. Determining the extent and severity of disease is critical to selecting appropriate medical and surgical management. The extent of disease should be characterized anatomically (e.g., Montreal classification as proctitis, E1; left-sided colitis, E2; or extensive colitis, E3). ^{6 7} The presence or absence of perianal disease should be documented as part of the assessment for Crohn's disease (CD), which can be a confounding alternative diagnosis that, if present, might alter the medical and surgical approaches. Disease severity is most commonly classified according to the Truelove and Witts criteria or Mayo Score. ⁸ The use of a clinical scoring index can help facilitate comparative evaluations over time and can be particularly helpful when patients have worsening clinical or endoscopic disease severity.

In addition to routine blood tests, abdominal imaging to exclude toxic megacolon, stool cultures and Clostridium difficile testing, and early endoscopy with mucosal biopsies for cytomegalovirus is essential. Intravenous methylprednisolone 20 mg or hydrocortisone 100 mg three times daily is typically recommended as first-line therapy upon admission to the hospital; higher doses have not been proven more effective, and are associated with increased adverse effects. ⁹ Patients should be monitored for clinical response to medical therapy including decreased stool frequency, decreased hematochezia, a reduction in serum C-reactive protein, and a general improvement in their overall condition. Surgical consultation should be obtained within 72 hours of initiating intravenous corticosteroids for hospitalized UC patients who do not show signs of improvement; earlier operative intervention has been associated with decreased postcolectomy complications. ¹⁰

The initial communications between gastroenterology and surgery at this juncture is critical. When exactly should surgery be consulted? Consultation too early results in unnecessary consultations, and perhaps increased anxiety for patients who may not need surgery. Consultation too late may result in complications from prolonged medical therapy, need for urgent activation of the surgical team and resources, and worse postoperative patient outcomes. ¹¹ There was significant variation between “IBD experts” and nonexperts with regard to “when to call the surgeon” in a vignette-based survey. ¹² In general, “experts” tended to consult surgery earlier in the hospital course. This may reflect referral-center bias, where many experts practice. However, there is general consensus among surgeons that earlier consultation is favored, particularly among sicker patients. ¹¹ One barrier to early surgical consultation may reflect a desire to avoid unnecessary anxiety to patients, as both gastroenterologists and patients generally favor avoidance of surgery in the setting of severe acute-on-chronic UC if there is a reasonable possibility that medical therapy will be effective. ^{13 14} However, there is also a need for adequate patient support and education to better adapt to patient preferences before and after surgery. ¹⁵

Follow-Up Evaluation

If there is no improvement in the 3 to 5 days after initiation of corticosteroids, intravenous infliximab at a dose of 5 to 10 mg/kg is typically recommended as “rescue therapy” for patients naive to infliximab. ¹⁶ For those who are infliximab-experienced, without response or with loss of response, cyclosporin can be considered in the appropriate clinical setting. ¹⁶ Other biologic therapies have not been shown to be effective in the ASUC, although a small case series with off-label use of high-dose tofacitinib suggests potential efficacy in this setting. ¹⁷ Both cyclosporine and infliximab have a mean response time of approximately 5 to 7 days in randomized controlled trials, with approximately 70% rates of colectomy-free survival at 90 days. ^{18 19 20} Patients should be closely observed during this initial 7-day treatment window by both the gastroenterologist and the surgeon, with colectomy reserved for patients who do not respond appropriately or clinically worsen during this interval. The gastroenterologist and surgeon should communicate regularly on the patient's progress, with consideration of clinical worsening and adverse effects of medical therapy as paramount considerations for surgical planning.

The role of second-line rescue therapy (cyclosporine for infliximab nonresponders or infliximab for cyclosporine nonresponders) remains undefined. Although colectomy-free rates may approach 40 to 60% at 1 year after the acute episode, ²¹ the potential risks of combined immunosuppression can be considerable. A systematic review documented that adverse events, serious infection, and death occurred in 23, 7, and 1% of patients treated with this approach, respectively. ²² Prolonged nonoperative care of these patients can exhaust their physiologic reserve and put them at high risk for increased morbidity, including colonic perforation. ¹¹ The gastroenterologist should be cognizant that surgical healing requires a functional immune system. Prolonged immunosuppression with multiple immunosuppressants including corticosteroids as well as malnutrition that frequently occurs in ASUC may portend a more complicated postoperative course in patients requiring colectomy. ^{23 24}

Surgical Evaluation

For patients not responding to medical therapy after 5 to 7 days, or with clinical deterioration at even earlier stages, surgical planning should be initiated. Colorectal surgical input at this juncture will begin with an operative risk assessment and maneuvers to improve postoperative outcomes. Small bowel cross-sectional imaging with either computerized tomography or magnetic resonance imaging with enterography protocols, if not already performed, is important to rule out CD. Patients presenting with poor nutritional status should be treated with adequate nutritional support. However, total parenteral nutrition with bowel rest, while not studied in UC patients since the 1980s and 1990s, has not shown a benefit over oral nutrition with regard to an improvement in clinical parameters, inflammatory signs, nutritional status, or decreased rates of colectomy. ^{25 26} Minimizing preoperative narcotic use should be emphasized to both the patient and IBD gastroenterologist. A pain management consultation may be useful to minimize narcotic pain medication perioperatively as narcotics may be a risk factor for increased infectious complications and mortality. ²⁷ Correction of preoperative anemia may not improve surgical outcomes as perioperative blood transfusion may increase postoperative infectious complications. ²⁸

Early surgical consultation should be considered to optimize patient education and position surgery as a relevant treatment option when there has been an insufficient response to escalation of medical therapy. This also allows for improved longitudinal evaluation of patients' clinical course and ongoing discussion with the gastroenterology team. In addition, discussion of the stoma with a surgeon, reinforced with enterostomal nurse input, is invaluable to patients facing a stoma, even if the stoma is temporary (to facilitate stoma education, establish perioperative ostomy care, alleviate patients' anxiety, and allow time for patients' questions to be answered).

Steroid and biologic drug use will greatly impact the surgical approach and predict postoperative recovery. Although the efficacy of corticosteroids for the treatment of acute and refractory UC has been well established, preoperative exposure to corticosteroids is associated with adverse postoperative outcomes. ²⁹ Preoperative high-dose corticosteroids, defined as > 20 mg of prednisone equivalents per day, is significantly associated with increased postoperative infectious complications. ³⁰

Immunomodulators (e.g., 6-mercaptupurine, azathioprine, and methotrexate), originally used as monotherapy for maintenance of remission before the era of biologic therapy and now used in conjunction with biologics to reduce immunogenicity primarily associated with anti-tumor necrosis factor (TNF) agents, have not been associated with increased postoperative complications after surgery for UC in single-center series and systematic reviews. ^{31 32}

Whether or not anti-TNF therapy is associated with adverse postoperative outcomes in the setting of UC has been a topic of controversy based on single-center, retrospective studies. While the majority of studies show no significant association between the use of preoperative anti-TNF therapy and postoperative complications, ^{33 34} the two largest, single-center series evaluating preoperative exposure to anti-TNF therapy at the time of urgent colectomy showed significantly increased rates of anastomotic leak and pelvic sepsis with anti-TNF exposure. ^{35 36} In contrast, a recent multicenter prospective study (the PUCCINI trial) did not show any association between infliximab or associated drug concentrations and adverse postoperative outcomes, although only about one-third of these operations were for UC, of which 75% were elective or staged procedures. ³⁷ Similarly, a single-center study of preoperative anti-TNF drug concentrations from 94 consecutive UC patients found no association between increased serum drug concentrations and adverse outcomes after surgery. ³⁸

The literature is more controversial regarding preoperative exposure to newer classes of biologics and postoperative outcomes, particularly vedolizumab. Some retrospective series have reported no significant increases in postileal pouchanal anastomosis (IPAA) complications following preoperative exposure to vedolizumab ^{39 40} but a multicenter, retrospective review including both UC and CD patients reported significantly increased rates of infectious complications after abdominal operations in patients exposed to vedolizumab compared with patients exposed to anti-TNF medication. ⁴¹ Furthermore, a matched case–control study suggested increased risk of postoperative infection among vedolizumab-treated patients with UC undergoing colectomy. ⁴² In contrast, preoperative serum vedolizumab concentrations have not been associated with postoperative outcomes in the IBD population. ³⁹ There are no current publications assessing postoperative outcomes among patients treated with ustekinumab, an anti-interleukin-12/23 agent approved for UC treatment in 2019. Similarly, tofacitinib, a Janus-kinase inhibitor approved for UC treatment in 2018, has also not yet been evaluated with regard to postoperative outcomes, although increased risks of thromboembolic events associated with tofacitinib suggest that its use in hospitalized patients with IBD undergoing surgery, already at increased thromboembolic risk, might be limited.

Given the increased risks of perioperative morbidity associated with some medical therapies, it is important that the gastroenterologist and colorectal surgeon communicate effectively ( Fig. 1 ). Gastroenterologists contemplating a change or escalation of therapy in a patient with UC facing surgery should inform and discuss the treatment approach and goals of therapy with the surgeon. Similarly, surgeons consulted on patients with medication profiles that put them at increased perioperative risk should communicate with the gastroenterologist to ensure that the patient is on optimized treatment prior to a planned operation. For example, for patients on chronic corticosteroids, opportunities to minimize steroid dosage without risking disease flare should be sought.

Fig. 1.

Flowchart outlining collaboration between surgeon and gastroenterologist.

Psychosocial Considerations

Patients with IBD have a high incidence of anxiety and depression. ^{43 44 45} Furthermore, those with more medically refractory disease may have even greater anxiety associated with fear of surgical complications, postoperative care, loss of work/school/productivity, body dysmorphia particularly related to the presence or possibility of an ostomy, burden on caregivers, and more. Both the gastroenterologist and the surgeon have opportunities to recognize and address anxiety by providing realistic expectations, education around the disease and the surgical approach, and referral as appropriate to mental health specialists including social workers, psychologists, and psychiatrists. Enterostomal therapists play an important role as well in “demystifying” issues around having a stoma that can empower patients with realistic expectations and knowledge.

There are many forms of communication that can take place between the gastroenterologist and the surgeon, and communication styles will vary by health care system and individual preferences. One international quality measure for IBD Centers of Excellence is to have a regular multidisciplinary case conference attended by gastroenterologists, surgeons, and radiologists to review specific patient details, disease course, and management plans specifically related to complex care decisions including surgery. ⁵ Gastroenterologists and surgeons can and should communicate directly as well, via phone, text, or in-person meetings. Communications may be among trainees on respective gastrointestinal or surgical services. Communication should always be with mutual respect for each other's perspective and discipline, and trust in the other's expertise. Given that patients hospitalized with UC need expertise from both fields, it is incumbent on the experts to work together in the best interest of the patient.

Conclusion

The hospitalized ASUC patient is a complex patient that cannot be adequately treated alone either by the IBD gastroenterologist or colorectal surgeon. The multidisciplinary approach, using timely and interactive discussions improve the quality of care and the outcome of these patients. Nothing is more helpful than IBD gastroenterologists telling their patients it is time for surgery and emphasize that surgery cannot be considered a “failure” but rather another step on the therapeutic ladder. Similarly, surgeons can help facilitate care by communicating and coordinating with the gastroenterologist to optimally prepare patients for surgery to optimize postoperative outcomes.

Funding Statement

Funding None.