What is the management approach for ulcerative colitis (UC) with active bleeding?

Management of Ulcerative Colitis with Active Bleeding

For ulcerative colitis with active bleeding, intravenous corticosteroids (methylprednisolone 40-60 mg/day or hydrocortisone 100 mg four times daily) should be initiated immediately as the mainstay of treatment for severe disease. 1

Initial Assessment and Classification

• Assess severity using Truelove and Witts' criteria:

  • Severe UC: ≥6 bloody stools/day, tachycardia, fever, anemia, elevated ESR/CRP
  • Moderate UC: Between mild and severe criteria
  • Mild UC: <4 stools/day, no systemic symptoms, normal labs

• Diagnostic workup:

  • Stool studies: Culture, C. difficile testing, parasites
  • Unprepared flexible sigmoidoscopy to confirm diagnosis and exclude CMV infection
  • Laboratory tests: CBC, CRP, ESR, electrolytes, albumin, liver function
  • Abdominal radiography if colonic dilatation suspected

Treatment Algorithm

Severe UC with Active Bleeding (Hospitalized Patient)

1. First-line therapy:

   • IV corticosteroids (methylprednisolone 40-60 mg/day or hydrocortisone 100 mg QID) 1, 2
   • IV fluid and electrolyte replacement (potassium ≥60 mmol/day)
   • Monitor response daily with physical exam, vital signs, stool chart, labs

2. Supportive measures:

   • VTE prophylaxis with subcutaneous heparin
   • Blood transfusion to maintain adequate hemoglobin
   • Enteral nutrition if malnourished
   • Avoid opioids due to risk of toxic megacolon 1

3. If no improvement by day 3:

   • Consider rescue therapy with either:
     • Infliximab 5 mg/kg IV at weeks 0,2, and 6
     • Cyclosporine 2 mg/kg/day IV 1
   • Early surgical consultation

4. Indications for urgent colectomy:

   • Free perforation
   • Life-threatening hemorrhage with hemodynamic instability
   • Toxic megacolon with clinical deterioration
   • Failure to respond after 7 days of rescue therapy 1

Mild to Moderate UC with Bleeding (Outpatient)

1. First-line therapy:

   • For proctitis: Rectal 5-ASA therapy 2
   • For left-sided or extensive disease: Oral 5-ASA 2.0-4.8 g/day 2
   • Consider combination of oral and rectal 5-ASA for better response 2

2. If no response to 5-ASA within 4-8 weeks:

   • Add oral corticosteroids (prednisone 40-60 mg/day) 2
   • Evaluate response within 2 weeks 2

3. For steroid-dependent or refractory disease:

   • Consider biologic therapy:
     • Infliximab or vedolizumab preferred as first-line biologics 2
     • Adalimumab or golimumab as alternatives
     • Tofacitinib as another option 2
   • Consider combination with immunomodulators (thiopurines) for enhanced efficacy 2

Maintenance Therapy After Remission

• For 5-ASA-induced remission:

  • Continue same therapy (oral 5-ASA ≥2 g/day) 2
  • For distal disease, continue rectal therapy 2

• For corticosteroid-induced remission:

  • Taper corticosteroids
  • Start oral 5-ASA ≥2 g/day 2
  • Consider thiopurines for steroid-dependent patients 2

• For biologic-induced remission:

  • Continue biologic therapy with or without immunomodulators
  • 5-ASA can be discontinued in patients who previously failed 5-ASA and are now on biologics 2

Monitoring and Follow-up

• Regular assessment of symptoms, physical examination
• Laboratory monitoring: CBC, inflammatory markers, liver function
• Endoscopic evaluation to confirm mucosal healing
• Colonoscopy surveillance starting 8 years after disease onset

Common Pitfalls to Avoid

• Delaying treatment escalation in non-responders
• Prolonged steroid use without steroid-sparing strategies
• Failure to recognize infectious causes (especially C. difficile)
• Delaying surgical consultation in severe cases
• Routine use of antibiotics without evidence of infection 1

The management of UC with active bleeding requires prompt assessment of disease severity and appropriate treatment escalation. While 5-ASA compounds are effective for mild-moderate disease, severe UC with active bleeding necessitates hospitalization and IV corticosteroids, with close monitoring and timely consideration of rescue therapy or surgery if needed.