Patients with fulminant attacks of ulcerative colitis should be hospitalized for aggressive fluid and electrolyte resuscitation and careful observation for the development of complications. Patients with complications such as significant gastrointestinal hemorrhage, toxic megacolon, and bowel perforation should also be admitted with consultation to both a gastroenterologist and a surgeon.13 In addition to toxic megacolon, the indications for surgery include colonic perforation, massive lower-Gl bleeding, suspicion of colon cancer, and disease that is refractory to medical therapy (large doses of steroids required to control the disease). The surgical treatment options include proctocolectomy with ileostomy, ileostomy with a Koch pouch, proctocolectomy with an ileoanal pouch, or colectomy with ileorectal anastomosis. Age and patient acceptance often influence the choice of surgical procedure, with the increased performance of continent procedures. Unlike the effects of surgery in Crohn's disease, surgical intervention is curative in ulcerative colitis.

Patients with mild to moderate disease can be discharged from the ED. Close follow-up should be arranged with the patient's medical physician or gastroenterologist, and any adjustment in medical therapy discussed. In addition, the patient should be instructed to eat a low-residue diet. Patients should be instructed to return if symptoms do not improve or worsen. Particular attention should focus on the quantity of diarrhea, toleration of oral intake, and associated symptoms such as fever, rectal bleeding, or abdominal pain.

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