What is the best management plan for a patient with severe acute ulcerative colitis (UC) and signs of toxic colitis, presenting with bloody diarrhea, abdominal pain, tenderness, fever, anemia, leukocytosis, hypoalbuminemia, and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)?

Management of Severe Acute Ulcerative Colitis with Toxic Colitis

The best management plan is B: IV steroids alone. Intravenous corticosteroids are the cornerstone and first-line treatment for acute severe ulcerative colitis (ASUC), and there is no evidence supporting the routine addition of rectal steroids in this critically ill population 1.

Rationale for IV Steroids as Monotherapy

Intravenous corticosteroids remain the mainstay of conventional therapy for ASUC. The most recent British Society of Gastroenterology guidelines (2025) explicitly state that hydrocortisone 100 mg four times daily or methylprednisolone 30 mg every 12 hours should be administered intravenously 1. Methylprednisolone is preferred as it has less mineralocorticoid effect and causes significantly less hypokalaemia 1.

• Approximately 67% of patients with ASUC respond to IV corticosteroids alone, based on a systematic review of 32 trials involving 1991 patients 1
• Higher doses offer no additional benefit and are associated with increased adverse events 1
• Treatment duration should be limited to 7-10 days maximum, as prolonged courses carry no additional benefit and increase toxicity 1

Why Not Rectal Steroids in This Setting?

The guidelines do not recommend adding rectal steroids in patients with severe acute UC presenting with systemic toxicity and toxic colitis features 1. The key distinctions are:

• Rectal therapies are appropriate for mild-to-moderate distal colitis, not for systemically toxic patients requiring hospitalization 2, 3
• This patient has systemic toxicity (fever, anemia, leukocytosis, hypoalbuminemia, elevated inflammatory markers) indicating severe disease requiring systemic therapy 1
• Toxic colitis represents a medical emergency where the priority is rapid systemic immunosuppression, not topical therapy 1, 4

Critical Management Components Beyond Steroids

While IV steroids are the primary treatment, comprehensive supportive care is essential:

• IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day, as hypokalaemia can promote toxic dilatation 1
• Low-molecular-weight heparin for thromboprophylaxis, as rectal bleeding is NOT a contraindication 1
• Stool cultures and Clostridioides difficile testing to exclude superimposed infection 1
• Flexible sigmoidoscopy to confirm diagnosis and exclude CMV infection 1
• Daily monitoring of stool frequency, vital signs, complete blood count, CRP, albumin, and electrolytes 1

Assessment for Rescue Therapy

Patients should be assessed for clinical and biochemical response after 3-5 days of IV corticosteroids to determine need for salvage medical therapy or surgery 1, 4.

• If inadequate response by day 3-5, consider rescue therapy with infliximab (5 mg/kg) or ciclosporin (2 mg/kg/day) 1, 5
• Both rescue therapies are similarly effective, with approximately 85% response rates by day 7 1, 5
• Patients remaining on ineffective medical therapy beyond 7-10 days suffer high morbidity associated with delayed surgery 1

Common Pitfalls to Avoid

• Do not use oral or rectal steroids as primary therapy in systemically toxic patients—this represents inadequate treatment 1
• Avoid opioids and anti-diarrheal agents as they may precipitate colonic dilatation 1
• Do not delay surgical consultation—joint management by gastroenterology and colorectal surgery is essential from admission 1
• Do not extend IV steroid therapy beyond 7-10 days without escalating to rescue therapy or surgery 1

Mortality and Surgical Considerations

Overall mortality of ASUC is 1%, but is significantly higher in patients older than 60 and those with comorbidities 1. This 50-year-old patient with 10-year disease history presenting with toxic colitis features requires aggressive medical management with early surgical involvement, as approximately 20-29% of ASUC patients require colectomy during the same admission 1.