A53-27 Use of Fludrocortisone as Adjunct Hemodynamic Support in Septic Shock Secondary to Ulcerative Colitis-Related Bowel Perforation With Peritonitis

Introduction Bowel perforation is a rare but catastrophic complication of ulcerative colitis (UC), with mortality rates approaching 70% due to ensuing peritonitis and septic shock. Despite its clinical severity, there are no established guideline-driven recommendations for hemodynamic management in this population, particularly concerning the type and dosing of corticosteroids. We present a case of fulminant septic shock following UC-related bowel perforation with peritonitis in which adjunctive fludrocortisone contributed to hemodynamic stabilization and successful vasopressor de-escalation. Case Description A 48-year-old woman with UC, not on maintenance therapy, was admitted with abdominal pain and diarrhea. Colonoscopy confirmed an acute UC flare, and she was initiated on intravenous methylprednisolone. On hospital day 11, she developed worsening abdominal pain; computed tomography demonstrated extensive pneumoperitoneum. She underwent emergent exploratory laparotomy with washout and subtotal colectomy. Postoperatively, she progressed to refractory septic shock and acute respiratory failure requiring intubation. She was on maximal vasopressors with stress dose corticosteroids for septic shock; however, she remained profoundly hypotensive and critically ill. Fludrocortisone was initiated as adjunctive mineralocorticoid therapy for additional hemodynamic support to improve perfusion. Over subsequent days, vasopressor requirements declined, and she achieved sustained hemodynamic stability. Once stable, fludrocortisone was discontinued and she was started on intravenous loop diuretic to treat hypervolemia due to resuscitation. The patient, ultimately, required prolonged intensive care, followed by transfer to long-term acute care for rehabilitation. She subsequently recovered and progressed to outpatient rehabilitation with return to baseline functional status. Discussion This case underscores the potential value of fludrocortisone in managing refractory septic shock associated with bowel perforation and peritonitis as complications of UC. Adding mineralocorticoid therapy to standard stress dose corticosteroids for septic shock may offer physiologic benefit in select patients by enhancing vascular responsiveness and restoring perfusion. In the absence of clinical guidelines for this high-mortality scenario, early consideration of adjunctive mineralocorticoid may provide the perfusion support to serve as a bridge to stability when conventional interventions are insufficient. Our case highlights the need for further investigation into optimal corticosteroid strategies for UC-related septic shock with peritonitis to provide guidance for clinical practice and improve patient outcomes.