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) are the mainstay of treatment for severe acute ulcerative colitis with toxic colitis features and should be initiated immediately. 1

First-Line Treatment

• IV Corticosteroids:

  • Methylprednisolone 40-60 mg/day OR hydrocortisone 100 mg four times daily 1
  • This is the cornerstone of initial management for severe UC

• Supportive Care (must be implemented concurrently):

  • IV fluid and electrolyte replacement (ensure potassium ≥60 mmol/day)
  • Subcutaneous heparin for thromboembolism prophylaxis
  • Blood transfusion if needed to maintain adequate hemoglobin levels
  • Nutritional support if malnourished 1

Diagnostic Workup

• Unprepared flexible sigmoidoscopy and biopsy to:
  • Confirm diagnosis
  • Exclude cytomegalovirus infection
• Stool cultures and Clostridium difficile toxin assay 1
• Daily abdominal radiography if colonic dilatation is present

Monitoring Response

• Daily physical examination to assess abdominal tenderness
• Record vital signs four times daily
• Maintain stool chart documenting frequency, character, and presence of blood
• Laboratory tests every 24-48 hours:
  • Complete blood count
  • ESR/CRP
  • Electrolytes
  • Albumin
  • Liver function tests 1

Assessment of Response and Rescue Therapy

• Critical Decision Point: Day 3 of IV steroids
  • If no improvement by day 3, initiate rescue therapy:
    • Infliximab 5 mg/kg IV at weeks 0,2, and 6 OR
    • Cyclosporine 2 mg/kg/day IV 1, 2
  • Early surgical consultation should be obtained at this point

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

Important Considerations and Pitfalls

• Avoid delaying treatment escalation in non-responders to IV steroids
• Avoid prolonged steroid use without implementing steroid-sparing strategies
• Avoid opioids when possible due to risks of dependence, infection, and gut dysmotility
• Do not routinely administer antibiotics unless there is evidence of infection 1
• Do not delay surgical consultation in severe cases, as this increases surgical morbidity and mortality 3

Evidence for Efficacy of Treatment Approach

• Historical colectomy rates for severe UC were 30-40%, but with early identification of steroid failure and prompt initiation of rescue therapies, current rates can be reduced to as low as 6.5% 4
• Infliximab has demonstrated efficacy in inducing clinical response and remission in patients with moderate to severe UC, with 65% of patients showing response at week 8 compared to 29% with placebo 2

The management of this patient with severe acute UC and toxic colitis requires immediate IV steroids, close monitoring, and readiness to escalate to rescue therapy if needed by day 3. Rectal steroids alone would be insufficient for this severe presentation, making option B (IV steroids) the correct management choice.