Handling the Hot Colon

Abstract

Fulminant colitis is a life-threatening condition that could be complicated by a toxic megacolon. Fulminant colitis occurs in 6% to 10% of patients with ulcerative colitis (UC) and toxic megacolon in 2% to 3%. Other possible causes are Crohn disease, indeterminate colitis, and occasionally infectious or drug-induced colitis. Fulminant colitis must be managed by a medicosurgical team, which has to consider surgery when needed. Restorative proctocolectomy with ileal pouchoanal anastomosis (IPAA), either in 1 or 2 steps, is the procedure of choice in UC in the absence of abdominal sepsis, multiple organ system failure, malnutrition, or severe hemorrhage. IPAA is not indicated in Crohn disease because of the high risk of postoperative complications and recurrence. IPAA can be considered in indeterminate colitis and other conditions. Thus, the decision for IPAA depends partially on the diagnosis. The pathologist should thus be a member of the medicosurgical team monitoring the patient because of this diagnostic responsibility. He or she must try to reach a precise diagnosis. If fulminant colitis occurs in a patient with a history of chronic idiopathic inflammatory bowel disease, review of previous biopsies is essential. If it is the initial presentation, the pathologist should examine carefully colorectal biopsies obtained in the preoperative phase, if available, to exclude infections or Crohn disease. When the patient is operated, the surgical specimens should be examined systematically. If Crohn disease is suspected, any decision for IPAA should be delayed for 12 months or more. If no clear distinction is possible between UC and indeterminate colitis, IPAA can be considered, but even then, a delay of the procedure is useful to follow the natural history of the disease.