Fulminant Colitis: When an Ulcerative Colitis Flare Becomes a Medical Emergency

For some people with ulcerative colitis (UC), the symptoms are mild. But for others, symptoms can quickly turn into a medical emergency called fulminant colitis.

Fulminant colitis is essentially a very severe flare that develops quickly, often without warning, says Rudolph Bedford, MD, a gastroenterologist at Providence Saint John’s Health Center in Santa Monica, California. “It can come on within days.”

• Bloody diarrhea, usually around 10 times a day
• Severe urgency (to the point where you may not be able to leave the bathroom, says Dr. Bedford)
• Severe abdominal pain or cramping
• Dizziness
• A fever
• A racing heart

• Toxic megacolon, where the colon muscles stop working, and gases and other materials inside start to build up. This causes the colon to stretch and toxins to leak into the bloodstream.

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• Bowel perforation, or a hole in your colon
• Severe bleeding

Fulminant colitis happens when the colon becomes severely inflamed. The inflammation stems from an overactive immune system, which mistakenly attacks the lining of the colon. The attacks can damage the colon lining and trigger symptoms.

Even people who have well-controlled UC can develop fulminant UC. But if you have undermanaged UC or continuously or frequently take steroids for it, you’re more at risk for fulminant UC. Sometimes the inflammation can get worse quickly and unexpectedly. “Patients who are not taking their medications appropriately tend to be at the highest risk,” says Bedford.

Certain severe gastrointestinal infections, such as Clostridioides difficile (C. diff), can also trigger inflammation that leads to fulminant colitis.

Fulminant colitis is an emergency. If you’re experiencing severe symptoms, you should go to the hospital immediately. Don’t eat or drink, and stop taking any antidiarrheal medications you may have been using, as they could make fulminant UC worse.

Once you’re there, the hospital may order imaging tests and possibly a sigmoidoscopy to see what’s happening inside your colon. You’ll also have blood and stool tests to check for markers of inflammation and possible infections.

• IV fluids and electrolytes to help you stay hydrated
• IV antibiotics
• IV immunosuppressant medications, such as corticosteroids
• In some cases, a biologic drug or another advanced immunosuppresant therapy

You’ll be monitored closely for several days after starting treatment. If medications haven’t done enough to control the fulminant colitis after three to five days, your care team may recommend emergency surgery, such as an end ileostomy or J-pouch surgery, to remove your colon and rectum.

Once inflammation and symptoms are under control, you’ll be able to go home. Most likely, your gastroenterologist will recommend making adjustments to the UC medications you take to better control inflammation, so you don’t have another severe flare.

Most people who experience fulminant UC make a full recovery — and don’t go on to have another episode. “Typically, once the patient is on appropriate therapy, the problem doesn’t recur,” says Bedford.

• Fulminant colitis is a rare but severe complication of ulcerative colitis that can develop rapidly.
• Without prompt treatment, fulminant colitis can turn life threatening. It’s important to seek emergency care if you’re having symptoms.
• Fulminant colitis is usually treated with medications by IV, but in rare instances, surgery may be necessary.