What is the best course of treatment for a 36-year-old male with ulcerative colitis (UC) on mesalamine (5-aminosalicylic acid) presenting to the emergency room (ER) with an acute flare-up of colitis?

Management of Acute Ulcerative Colitis Flare in a Patient on Mesalamine

For a 36-year-old male with ulcerative colitis on mesalamine presenting to the ER with an acute flare, intravenous corticosteroids should be initiated immediately as first-line therapy for this acute severe episode. 1

Assessment of Disease Severity

First, determine the severity of the flare using the Truelove and Witts' criteria:

• Stool frequency (>6 bloody stools/day indicates severe disease)
• Vital signs (tachycardia, fever)
• Laboratory markers (hemoglobin <10 g/dL, ESR >30 mm/h, CRP elevation)
• Physical examination for abdominal tenderness

Treatment Algorithm

1. Initial Management in ER

• Initiate IV corticosteroids immediately (typically IV hydrocortisone 100mg four times daily or equivalent)
• Obtain stool studies to rule out infectious causes (but don't delay steroid treatment)
• Order abdominal X-ray to assess for toxic megacolon (colonic dilatation >5.5cm)
• Establish IV access for fluid and electrolyte replacement
• Monitor vital signs every 4-6 hours
• Start subcutaneous heparin for thromboembolism prophylaxis 1

2. Monitoring During Hospitalization

• Daily physical examination for abdominal tenderness
• Stool chart recording frequency and character of bowel movements
• Laboratory tests every 24-48 hours (CBC, CRP, electrolytes, albumin, liver function)
• Daily abdominal X-ray if colonic dilatation present at admission
• Blood transfusion to maintain hemoglobin >10 g/dL 1

3. Response Assessment (within 3-5 days)

• If responding: Continue IV steroids for 3-5 days, then transition to oral prednisolone 40mg daily with gradual taper over 6-8 weeks 1
• If not responding: Consider rescue therapy with infliximab, cyclosporine, or surgical consultation 1

Optimizing Mesalamine Therapy

The patient is already on mesalamine but experiencing a flare, suggesting inadequate response to current therapy. After controlling the acute flare:

• Optimize mesalamine dosing to high-dose (4-4.8g/day) orally 1, 2
• Add rectal mesalamine (enemas or suppositories depending on disease extent) 1, 2
• Consider once-daily dosing to improve adherence 1, 2

Long-term Management After Flare

After achieving remission with corticosteroids:

1. Assess need for treatment escalation: If this is the second steroid course within a year or if the patient becomes steroid-dependent, escalate to thiopurines or biologics 1
2. Optimize maintenance therapy: Continue high-dose mesalamine (oral + topical) 1, 2
3. Monitor for medication side effects: Check renal function regularly while on mesalamine 1

Important Considerations and Pitfalls

• Mesalamine intolerance: Rarely, patients may develop paradoxical worsening of colitis with mesalamine. If symptoms worsen despite appropriate therapy, consider mesalamine intolerance 3
• Steroid complications: Monitor for hyperglycemia, hypertension, and psychiatric effects during steroid therapy
• Joint management: Severe UC should be managed jointly by a gastroenterologist and colorectal surgeon 1
• Patient education: Inform the patient about a 25-30% chance of needing colectomy in severe UC 1

Follow-up Plan

• Schedule follow-up within 2 weeks of discharge
• Monitor for steroid side effects during taper
• Consider fecal calprotectin monitoring every 3 months to detect subclinical inflammation 2
• Evaluate need for maintenance therapy escalation if frequent flares occur

This approach prioritizes rapid control of inflammation to reduce morbidity and mortality while establishing an effective long-term maintenance strategy to prevent future flares.