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 UC and toxic colitis is to start IV steroids immediately, followed by infliximab if no improvement after 3 days, then cyclosporine if infliximab fails, and finally subtotal colectomy if medical therapy fails (option B).

Initial Management

• First-line therapy: IV steroid regimens such as Methylprednisolone 60 mg/day or Hydrocortisone 100 mg four times daily 1
• Concurrent supportive measures:
  • IV fluid and electrolyte replacement with potassium supplementation (at least 60 mmol/day)
  • Subcutaneous low-molecular-weight heparin for thromboembolism prophylaxis
  • Blood transfusion to maintain hemoglobin above 8-10 g/dL
  • Nutritional support, preferably enteral nutrition for malnourished patients 1

Monitoring Response

• Daily physical examination to evaluate abdominal tenderness
• Record vital signs four times daily
• Maintain a stool chart documenting frequency, character, and 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

Rescue Therapy (Day 3)

• Assess response to IV steroids after 3 days of treatment
• If no improvement or clinical deterioration, initiate rescue therapy and surgical consultation 1
• First-line rescue: Infliximab 5 mg/kg IV at weeks 0,2, and 6
  • Infliximab has shown efficacy in inducing clinical response (65-69% at week 8) and remission (28-34% at week 8) in patients with UC 2
  • Approximately 70% short-term and 50% long-term response rates 3

Second-line Rescue (If Infliximab Fails)

• Second-line rescue: Cyclosporine 2 mg/kg/day IV 1
• Approximately 75% short-term and 50% long-term response to cyclosporine 3
• Long-term response improves in patients who are thiopurine naïve and started on thiopurines on day 7 3

Surgical Intervention

• Subtotal colectomy with ileostomy is indicated 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 1

Important Considerations

• Withdraw anticholinergic, anti-diarrheal, NSAIDs, and opioid medications as they may precipitate colonic dilatation 1
• Antibiotics should not be administered routinely unless there is evidence of infection 1
• Perform unprepared flexible sigmoidoscopy and biopsy to confirm diagnosis and exclude cytomegalovirus infection 1
• Obtain stool cultures and test for Clostridium difficile toxin 1

Common Pitfalls to Avoid

1. Delaying treatment escalation in non-responders
2. Prolonged steroid use without steroid-sparing strategies
3. Failing to recognize infectious causes
4. Delaying surgical consultation in severe cases
5. Using antibiotics routinely without evidence of infection 1

Maintenance Therapy (After Acute Phase)

• All patients should receive maintenance therapy after the acute phase resolves
• Options include oral mesalamine ≥2g/day, azathioprine or mercaptopurine, biologics, or tofacitinib 1
• For biologic-induced remission, continue biologic therapy with or without immunomodulators 1

The stepwise approach of IV steroids → infliximab → cyclosporine → surgery represents the current evidence-based management strategy for severe acute UC with toxic colitis, with time-bound decision making being crucial to reduce mortality to below 1% 3.