What is the best course of treatment for a patient with severe ulcerative colitis, dehydration, malnutrition, and frequent liquid bowel movements with discharge and occasional blood?

Management of Acute Severe Ulcerative Colitis

Patients with severe ulcerative colitis presenting with dehydration, malnutrition, and frequent bloody diarrhea require immediate hospitalization for intensive treatment to prevent life-threatening complications and reduce mortality risk. 1

Initial Assessment and Management

• Immediate hospitalization is required for this patient showing signs of acute severe ulcerative colitis (ASUC) with:

  • Dehydration and malnutrition
  • Frequent liquid bowel movements with blood
  • Abdominal pain and weakness
  • Inability to be away from bathroom

• Initial interventions:

  • Intravenous fluid and electrolyte replacement to correct dehydration 1
  • Low-molecular-weight heparin for thromboembolism prophylaxis 1
  • Correction of anemia (blood transfusion if hemoglobin <10 g/dL) 1
  • Nutritional support (preferably enteral if tolerated) 1

Medical Treatment

1. First-line therapy:

   • Intravenous corticosteroids: methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily 1, 2
   • Continue for 3-5 days with daily monitoring of:
     • Vital signs (pulse, temperature)
     • Stool frequency and characteristics
     • Abdominal examination
     • Laboratory tests (CBC, electrolytes, albumin, CRP) every 24-48 hours 2

2. Assessment of response by day 3:

   • If improving: Continue IV steroids for 5-7 days, then transition to oral prednisolone
   • If no improvement or worsening: Initiate rescue therapy 1

3. Rescue therapy options (if no response to IV steroids by day 3):

   • Infliximab: 5 mg/kg IV at 0,2, and 6 weeks, then every 8 weeks 3
   • Cyclosporine: 2 mg/kg/day IV 1, 2

4. Surgical consultation:

   • Should be obtained early in the course of hospitalization
   • Colectomy should be considered if no response to 7 days of rescue therapy or earlier if clinical deterioration 1

Warning Signs Requiring Urgent Surgical Intervention

• Free perforation
• Massive hemorrhage with hemodynamic instability
• Toxic megacolon
• Generalized peritonitis
• Clinical deterioration despite optimal medical therapy 1

Maintenance Therapy After Acute Episode

After achieving remission, the patient will need:

• Maintenance therapy with 5-ASA compounds (mesalamine ≥2g/day) for mild disease 2
• For this severe case, consider immunomodulators (azathioprine/6-MP) or biologics (infliximab, vedolizumab) or JAK inhibitors (tofacitinib) for long-term maintenance 2, 4

Practical Considerations for This Patient

• Accommodation needs: The patient's request for a lower bunk to access bathroom facilities should be granted as this is medically necessary to prevent complications and maintain dignity
• Bathroom access: Proximity to bathroom facilities is essential given the frequency and urgency of bowel movements
• Nutritional support: Implement nutritional assessment and supplementation to address malnutrition

Common Pitfalls to Avoid

• Delaying hospitalization in severe cases
• Prolonged steroid use without implementing steroid-sparing strategies
• Delaying surgical consultation in severe cases
• Failing to monitor for complications of both disease and treatment
• Inadequate thromboprophylaxis (UC patients have increased thrombotic risk)
• Inadequate nutritional assessment and support 2

The mortality rate for properly managed ASUC should be less than 1% in specialist centers, but delayed intervention can significantly increase this risk 1. This patient's presentation warrants immediate hospitalization and aggressive management to prevent further deterioration.