Management of Severe Acute Ulcerative Colitis with Toxic Colitis

The best management plan for a patient with severe acute ulcerative colitis with toxic colitis is IV steroids and infliximab (option B). 1

Initial Assessment and Classification

This 50-year-old patient with a 10-year history of ulcerative colitis presents with classic features of severe acute ulcerative colitis (ASUC): >8 bloody stools per day, abdominal pain, tenderness, fever, anemia, leukocytosis, hypoalbuminemia, and elevated inflammatory markers (ESR and CRP) 1
The presentation with toxic colitis represents a potentially life-threatening condition requiring immediate hospitalization and intensive management 1, 2
Initial workup should include blood tests (CBC, CRP, electrolytes, liver function), stool cultures, C. difficile testing, and flexible sigmoidoscopy to confirm diagnosis and exclude cytomegalovirus infection 1, 2

Intravenous corticosteroids remain the cornerstone of initial management for ASUC 1
The recommended regimen is either methylprednisolone 60mg daily or hydrocortisone 100mg four times daily 1
Higher doses of corticosteroids do not offer additional benefit and may increase adverse effects 1
Response to IV corticosteroids should be assessed after 3-5 days of therapy 1

Approximately one-third of patients with ASUC will not respond adequately to IV corticosteroids 1, 3
For patients who fail to respond to IV steroids after 3-5 days, rescue therapy with either infliximab or cyclosporine should be initiated 1
Given the patient's presentation with toxic colitis and severe symptoms, early consideration of rescue therapy with infliximab is warranted 1
Infliximab is FDA-approved for reducing signs and symptoms, inducing and maintaining clinical remission, and eliminating corticosteroid use in patients with moderately to severely active ulcerative colitis 4

IV steroids plus infliximab has shown superior efficacy compared to IV steroids alone in steroid-refractory ASUC 1
The combination of IV steroids and rectal steroids (option A) would be insufficient for toxic colitis, which requires systemic therapy and consideration of early rescue therapy 1
Cyclosporine (option C) is an alternative rescue therapy, but infliximab may be preferred due to its established long-term maintenance potential 1, 3
Surgical resection (option D) should be reserved for patients who fail medical therapy or develop complications such as perforation, toxic megacolon, or massive bleeding 1, 5

Thromboprophylaxis with low-molecular-weight heparin is essential as patients with ASUC have increased risk of thromboembolism 1, 2
Fluid and electrolyte replacement to correct dehydration and electrolyte imbalances 1, 2
Nutritional support if the patient is malnourished 1, 2
Blood transfusion to maintain hemoglobin >10 g/dL 1, 2

Close monitoring of vital signs, stool frequency, abdominal examination, and laboratory parameters (CRP, albumin) is crucial 1, 2
Joint management by gastroenterologists and colorectal surgeons is recommended 1
If no improvement is seen after 3-5 days of IV steroids, infliximab should be initiated at 5 mg/kg at weeks 0,2, and 6, followed by maintenance therapy 2, 4
Patients should be informed about a 25-30% chance of ultimately requiring colectomy despite optimal medical therapy 1, 2

Once remission is achieved, steroids should be gradually tapered over 6-8 weeks 1, 2
For long-term maintenance, infliximab should be continued at 5 mg/kg every 8 weeks 4
Corticosteroids should not be used for maintenance therapy due to significant adverse effects 1, 2