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 UC and toxic colitis, characterized by bloody diarrhea, abdominal pain, tenderness, fever, anemia, leukocytosis, hypoalbuminemia, and elevated Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP)?

Management of Severe Acute Ulcerative Colitis with Toxic Colitis

Intravenous (IV) steroids alone are the first-line treatment for severe acute ulcerative colitis with toxic colitis features and should be initiated immediately. 1

Initial Treatment

• IV corticosteroids:

  • IV hydrocortisone 100 mg four times daily or methylprednisolone 60 mg daily 2, 1
  • Duration: 7-10 days (extending beyond this period offers no additional benefit) 2
  • Response rate: approximately 67% of patients 2, 1
  • Higher doses are not more effective but increase adverse effects 2

• Supportive measures (must be implemented concurrently):

  • IV fluid and electrolyte replacement (potassium supplementation of at least 60 mmol/day) 2
  • Subcutaneous heparin for thromboembolism prophylaxis 2, 1
  • Blood transfusion to maintain hemoglobin >10 g/dl 2, 1
  • Nutritional support if malnourished 2, 1
  • Unprepared flexible sigmoidoscopy and biopsy to confirm diagnosis and exclude cytomegalovirus infection 2
  • Stool cultures and assay for Clostridium difficile toxin 2

Monitoring

• Daily physical examination to evaluate abdominal tenderness 2
• Record vital signs four times daily 2
• Stool chart to document frequency, character, and presence of blood 2
• Laboratory tests every 24-48 hours: CBC, ESR/CRP, electrolytes, albumin, liver function 2
• Daily abdominal radiography if colonic dilatation is present (transverse colon diameter >5.5 cm) 2, 1

Evaluation of Response and Rescue Therapy

• Evaluate response to IV steroids by day 3 of treatment 1

• If no improvement by day 3, consider rescue therapy options:

  1. Infliximab: 5 mg/kg IV at weeks 0,2, and 6 1, 3
  2. Cyclosporine: 2 mg/kg/day IV 2, 1, 4

• Joint management with colorectal surgery is essential 2

• Early surgical consultation should be obtained 1

Indications for Surgery

• Free perforation
• Life-threatening hemorrhage with hemodynamic instability
• Toxic megacolon with clinical deterioration or no improvement after 24-48 hours
• Failure to respond to medical therapy within 7 days of rescue therapy 1

Common Pitfalls to Avoid

1. Delaying treatment: Initiate IV steroids immediately upon diagnosis
2. Prolonging ineffective steroid therapy: Assess response by day 3 and consider rescue therapy or surgery if inadequate response
3. Inadequate monitoring: Frequent clinical, laboratory, and radiographic assessment is crucial
4. Delayed surgical consultation: Involve surgeons early in the management
5. Failure to recognize complications: Monitor for toxic megacolon, perforation, and massive hemorrhage

Why IV Steroids Alone (Option B) is Correct

The evidence clearly supports IV steroids alone as the first-line treatment for severe acute UC with toxic colitis. While rectal steroids can be beneficial in distal UC, in severe acute UC with toxic colitis features, the addition of rectal steroids (Option A) is not supported by the guidelines and may pose unnecessary risks in a patient with severe inflammation and potential for perforation 2, 1.

The European Crohn's and Colitis Organisation guidelines specifically state that "intravenous corticosteroids remain the mainstay of conventional therapy" for severe UC 2. Similarly, the British Society of Gastroenterology guidelines recommend intravenous fluid and electrolyte replacement along with IV steroids, without mentioning rectal steroids for severe disease 2.

The most recent evidence from Praxis Medical Insights, summarizing recommendations from the American Gastroenterological Association, confirms that "IV hydrocortisone 100 mg three to four times daily or equivalent is the standard initial treatment and should be initiated immediately" 1.