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 signs of toxic colitis, including 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

The best management plan for a 50-year-old patient with severe acute ulcerative colitis and toxic colitis is IV steroids initially, followed by infliximab if no improvement, then cyclosporine as a second rescue therapy, and finally subtotal colectomy if medical management fails (option B).

Initial Assessment and Management

• For patients with severe ulcerative colitis presenting with bloody diarrhea, abdominal pain, fever, and laboratory abnormalities (anemia, leukocytosis, hypoalbuminemia, elevated ESR/CRP), immediate hospitalization and IV corticosteroids are essential first-line therapy 1.
• Recommended IV steroid regimens:
  • Methylprednisolone 60 mg/day OR
  • Hydrocortisone 100 mg four times daily 2

Supportive Measures (to be implemented concurrently)

• IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day to prevent dehydration and electrolyte imbalance 2
• Subcutaneous low-molecular-weight heparin for thromboembolism prophylaxis 2, 1
• Blood transfusion to maintain hemoglobin above 8-10 g/dL 2
• Nutritional support if malnourished (enteral nutrition preferred over parenteral) 2
• Unprepared flexible sigmoidoscopy and biopsy to confirm diagnosis and exclude cytomegalovirus infection 2, 1
• Stool cultures and testing for Clostridium difficile toxin 2, 1

Monitoring Response to Treatment

• Daily physical examination to assess abdominal tenderness
• Vital signs monitoring four times daily
• Stool chart documentation (frequency, character, presence of blood)
• Laboratory tests every 24-48 hours (CBC, ESR/CRP, electrolytes, albumin, liver function)
• Daily abdominal radiography if colonic dilatation is present 1

Treatment Algorithm

1. First 48-72 hours: IV corticosteroids as initial therapy
2. Day 3 assessment: If no improvement or clinical deterioration, initiate rescue therapy and surgical consultation 2, 1
3. Rescue therapy options:
   • Infliximab 5 mg/kg IV at weeks 0,2, and 6 1, 3
   • If infliximab fails, try cyclosporine 2 mg/kg/day IV 2, 1
4. Surgical intervention: Subtotal colectomy with ileostomy if:
   • No improvement after 7 days of rescue therapy
   • Clinical deterioration during medical management
   • Complications such as free perforation, life-threatening hemorrhage, or generalized peritonitis 2, 1

Evidence for Rescue Therapies

• Infliximab has demonstrated effectiveness in severe UC with approximately 70% short-term response rate and 50% long-term response 4
• In clinical trials, infliximab showed significant improvement in clinical response, remission, and mucosal healing compared to placebo 3
• Cyclosporine (2 mg/kg/day) has shown similar efficacy to infliximab as rescue therapy, with approximately 75% short-term and 50% long-term response rates 4
• Both infliximab and cyclosporine are equally effective rescue therapies as demonstrated in randomized controlled trials 4, 5

Important Considerations and Pitfalls

• Avoid delaying treatment escalation in non-responders; timely decision-making is critical 1, 6
• Avoid prolonged steroid use without steroid-sparing strategies 1
• Withdraw anticholinergic, anti-diarrhoeal, NSAIDs, and opioid medications which may precipitate colonic dilatation 2
• Do not routinely administer antibiotics unless there is evidence of infection 2, 1
• Avoid delaying surgical consultation in severe cases 1
• Early multidisciplinary approach between gastroenterologists and colorectal surgeons is essential 2, 6

This management approach follows a step-up strategy that balances the risks of continued medical therapy against the risks of surgery, with the goal of reducing morbidity and mortality while preserving the colon when possible.