What is the initial treatment for acute severe ulcerative colitis?

Initial Treatment for Acute Severe Ulcerative Colitis

The initial treatment for acute severe ulcerative colitis (ASUC) is intravenous corticosteroids, specifically methylprednisolone 60 mg daily or hydrocortisone 100 mg four times daily, along with comprehensive supportive care. 1

Diagnosis and Initial Assessment

Upon presentation with suspected ASUC, the following steps should be taken:

1. Diagnostic confirmation:

   • Stool cultures and assay for Clostridioides difficile toxin 1, 2
   • Unprepared flexible sigmoidoscopy and biopsy to confirm diagnosis and exclude cytomegalovirus infection 1
   • Blood tests: Complete blood count, CRP, electrolytes, liver function tests 1, 2

2. Severity assessment using Truelove and Witts' criteria:

   • Six or more bloody stools per day
   • At least one of: tachycardia (>90 bpm), fever (>37.8°C), anemia (Hb <105 g/L), or elevated ESR (>30 mm/h) or CRP 1

Core Treatment Protocol

Immediate Interventions

1. Intravenous corticosteroids:

   • Methylprednisolone 60 mg daily OR
   • Hydrocortisone 100 mg four times daily 1
   • Continue for 7-10 days (longer courses offer no additional benefit and increase toxicity) 1

2. Supportive care:

   • IV fluid and electrolyte replacement (potassium supplementation ≥60 mmol/day) 1, 2
   • Venous thromboembolism prophylaxis with low-molecular-weight heparin and compression stockings 1, 2
   • Nutritional assessment and support (enteral preferred over parenteral) 1, 2
   • Blood transfusion to maintain hemoglobin >8-10 g/dL if needed 1

3. Medication adjustments:

   • Withdraw anticholinergics, anti-diarrheals, NSAIDs, and opioids 1
   • Consider topical therapy (corticosteroids or 5-ASA) if tolerated 1
   • Antibiotics only if infection is suspected 1

Monitoring Response

1. Day 3 assessment (critical decision point):

   • Poor response indicators: >8 stools/day OR 3-8 stools/day with CRP >45 mg/L 1
   • These criteria predict 85% colectomy rate and should trigger planning for rescue therapy 1

2. Day 7 assessment:

   • Poor response indicators: >3 stools/day OR visible blood 1
   • These criteria predict 40% colectomy rate in ensuing months 1

Rescue Therapy for Steroid-Refractory Disease

If inadequate response to IV corticosteroids by day 3-5:

1. Medical rescue options:

   • Infliximab: 5 mg/kg IV at 0,2, and 6 weeks, then every 8 weeks 3
   • Ciclosporin: 2 mg/kg/day IV (particularly useful in patients who should avoid steroids) 1

2. Surgical consultation:

   • Should be obtained early in the course of admission 1
   • Essential if no improvement or deterioration within 48-72 hours of medical therapy 2

Common Pitfalls and Caveats

1. Delayed treatment initiation: Do not delay IV corticosteroids while awaiting test results for infectious colitis 1

2. Inadequate electrolyte replacement: Hypokalaemia can promote toxic colonic dilatation 1, 2

3. Overlooking VTE prophylaxis: Rectal bleeding is NOT a contraindication to thromboprophylaxis 1, 2

4. Prolonged ineffective steroid therapy: Extending therapy beyond 7-10 days offers no additional benefit and increases toxicity 1

5. Missed infections: Always test for C. difficile and CMV, as these require specific treatments 1, 2

6. Nutritional neglect: Enteral nutrition is preferred over parenteral nutrition (9% vs 35% complication rate) 1

7. Delayed surgical consultation: Early involvement of colorectal surgery is essential for optimal outcomes 1

Multidisciplinary Approach

ASUC management requires coordinated care between:

• Gastroenterologists
• Colorectal surgeons
• Dietitians
• IBD nurses
• Pharmacists
• Stomal therapists (if surgery becomes necessary) 1

In areas without IBD expertise, discussion with a specialist center is strongly recommended to establish management plans and transfer thresholds 1.