Fulminant colitis.

Fulminant colitis is an important clinical challenge despite great progress in its management over the decades. Corticosteroids greatly reduced mortality and colectomy rates, however, case fatality rates remain at roughly 2%. The goal of medical therapy is to prevent colectomy while avoiding complications that may lead to death or worsen the outcome of colectomy, if this cannot be avoided. In addition to corticosteroids, cyclosporine and infliximab have been used in the setting of severe colitis. Rescue therapy with cyclosporine must be followed by maintenance therapy with a thiopurine agent if successful remission is to be maintained durably. Rescue therapy with infliximab may be followed by maintenance therapy with the same agent, or in some cases, by a thiopurine agent. Both cyclosporine and infliximab may be associated with increased risks, such as neurotoxicity in the case of cyclosporine, or opportunistic or serious infection in the setting of immune suppression from either agent. In either case, it is critical to avoid excessive prolongation of unsuccessful medical therapy if optimal surgical outcomes are to be achieved. A great deal of judgment is needed to guide the timing of colectomy, but it is clear that mortality increases as the time to colectomy is prolonged.