What is the best management plan for a 50-year-old patient with a 10-year history of Ulcerative Colitis (UC) presenting with severe acute ulcerative colitis and toxic colitis, characterized by frequent bloody diarrhea, abdominal pain, tenderness, fever, anemia, leukocytosis, hypoalbuminemia, elevated Erythrocyte Sedimentation Rate (ESR), and elevated C-Reactive Protein (CRP)?

Management of Severe Acute Ulcerative Colitis with Toxic Colitis

Intravenous corticosteroids (IV steroids) alone are the first-line treatment for severe acute ulcerative colitis with toxic colitis features. 1, 2

Initial Management

First-Line Therapy

• IV hydrocortisone 100 mg three to four times daily or equivalent is the standard initial treatment and should be initiated immediately 1
• Do not delay corticosteroid administration pending infectious colitis screening results 1
• The overall response rate to IV corticosteroids is approximately 67% 1
• There is no additional benefit to higher doses beyond the standard recommendation 1

Supportive Care Measures

• Daily monitoring of:

  • Hemodynamic status and vital signs
  • Abdominal examination
  • Stool frequency, consistency, blood presence, and volume
  • Laboratory parameters (CBC, electrolytes, CRP, albumin)
  • Serial abdominal X-rays (especially if colonic diameter >5.5 cm) 1, 3

• Venous thromboembolism prophylaxis with:

  • Subcutaneous or low molecular weight heparin
  • Graduated compression stockings (rectal bleeding is not a contraindication) 1, 3

• Nutritional support:

  • Enteral nutrition is preferred over parenteral nutrition
  • No role for routine fasting or bowel rest 1, 3
  • Assessment by a trained dietitian 1

Why IV Steroids Alone vs. IV + Rectal Steroids

The evidence clearly supports IV steroids alone rather than combined IV and rectal steroids for severe acute UC with toxic colitis for several reasons:

1. In toxic colitis, the systemic inflammatory burden is high, requiring systemic therapy 1, 2
2. Rectal administration may exacerbate symptoms in patients with severe disease and toxic features 3
3. Guidelines specifically recommend IV steroids as the cornerstone of therapy for ASUC 1, 2
4. The risk of colonic perforation is increased in toxic colitis, making rectal administration potentially dangerous 1

Multidisciplinary Management

Patients with ASUC should be managed by a multidisciplinary team including:

• Gastroenterologist
• Colorectal surgeon
• Gastroenterology nurse
• Dietitian
• Pharmacist
• Stomal therapist 1, 4

This should occur on a specialized gastrointestinal ward or with early consultation with an IBD-focused center 1

Assessment of Response

• Evaluate response to IV steroids by day 3 of treatment 1
• Failure to respond to IV steroids (approximately 30-40% of patients) requires prompt consideration of rescue therapy 2, 5

Rescue Therapy Options (if no response to IV steroids by day 3)

1. Infliximab: 5 mg/kg IV at weeks 0,2, and 6 1, 6

   • Consider accelerated induction with 10 mg/kg in severe cases 1
   • Particularly effective for inducing remission and mucosal healing 6

2. Cyclosporine: 2 mg/kg/day IV 1

   • Similar efficacy to infliximab in steroid-refractory cases 1

3. Surgical consultation: Should be obtained early in the course of treatment 1, 2

   • Colectomy should be considered if no improvement after 7 days of rescue therapy 1

Common Pitfalls to Avoid

1. Delaying initiation of IV steroids
2. Using opioids or anti-diarrheal agents (may precipitate toxic megacolon) 1
3. Failing to monitor for complications daily
4. Delaying surgical consultation in severe cases
5. Not recognizing predictors of poor response to medical therapy 5
6. Prolonging ineffective medical therapy beyond 7 days 2

Special Considerations

• Antibiotics should not be routinely administered unless there is evidence of infection 1
• Patients with previous TB exposure should have appropriate screening and treatment before immunosuppressive therapy 1
• Patients with toxic megacolon (colonic diameter >5.5 cm with systemic toxicity) require particularly close monitoring 1

In conclusion, the evidence strongly supports IV steroids alone as the first-line treatment for severe acute ulcerative colitis with toxic colitis, with careful monitoring and timely consideration of rescue therapy or surgery if no response is observed by day 3.