What is the initial treatment approach for acute onset ulcerative colitis?

Treatment of Acute Onset Ulcerative Colitis

For acute severe ulcerative colitis, immediately initiate intravenous corticosteroids (hydrocortisone 100 mg four times daily or methylprednisolone 40-60 mg daily) along with aggressive supportive care, without waiting for stool culture results. 1

Initial Assessment and Severity Classification

Classify disease severity using Truelove and Witts' criteria: severe disease is defined by bloody stool frequency ≥6/day plus at least one of: tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5 g/dl, or ESR >30 mm/h (CRP >30 mg/l can substitute) 2

Immediate Diagnostic Workup

• Perform unprepared flexible sigmoidoscopy with biopsies to confirm diagnosis, assess severity, and exclude cytomegalovirus infection 1
• Obtain stool cultures and test for Clostridium difficile toxin, which is more prevalent in severe UC and associated with increased morbidity and mortality 1
• Baseline laboratory tests: complete blood count, CRP, albumin, urea, electrolytes, and liver function tests 1
• Daily abdominal radiography if colonic dilatation (transverse colon diameter >5.5 cm) is detected at presentation 3

Treatment Algorithm by Disease Severity

Mild to Moderate Distal UC (Proctitis or Left-Sided)

First-line therapy: Topical mesalamine 1 g daily combined with oral mesalamine 2-4 g daily 3, 2

• For proctitis specifically, mesalamine 1g suppository once daily is first-line 2
• Topical corticosteroids are less effective than topical mesalamine and should be reserved as second-line therapy for patients intolerant of topical mesalamine 3
• If no improvement on combination therapy, escalate to oral prednisolone 40 mg daily with continued topical agents as adjunctive therapy 3
• Taper prednisolone gradually over 8 weeks according to severity and patient response 3

Acute Severe UC (Requiring Hospitalization)

Immediate management protocol:

Corticosteroid Therapy

• Start IV hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily immediately, without delaying for screening test results 1
• Treatment duration should be limited to 7-10 days maximum, as extending beyond this carries no additional benefit 1
• Overall response rate to IV corticosteroids is 67%, with 33% requiring colectomy 1

Aggressive Supportive Care (Concurrent with Steroids)

• IV fluid and electrolyte replacement: Potassium supplementation of at least 60 mmol/day to prevent hypokalaemia and toxic dilatation 1
• Thromboprophylaxis: Subcutaneous low-molecular-weight heparin (rectal bleeding is NOT a contraindication) 1
• Blood transfusion: Maintain hemoglobin above 8-10 g/dL 1
• Nutritional support: If malnourished, enteral nutrition preferred over parenteral 1
• Withdraw medications: Stop anticholinergics, anti-diarrheals, NSAIDs, and opioids which may precipitate colonic dilatation 1

Monitoring Protocol

• Physical examination daily to evaluate abdominal tenderness and rebound tenderness 3
• Record vital signs four times daily and more often if deterioration noted 3
• Stool chart documenting number, character, and presence of blood 3
• Measure FBC, ESR or CRP, serum electrolytes, serum albumin, and liver function tests every 24-48 hours 3

Day 3 Assessment: Critical Decision Point

Formal assessment of response is required on day 3 to identify patients needing rescue therapy 1

If no improvement or deterioration within 48-72 hours, proceed to rescue therapy or surgery 1

Rescue Therapy Options (Steroid-Refractory Disease)

For patients not responding to IV corticosteroids after 3-5 days, two equally effective rescue options exist 4:

Option 1: Infliximab 5 mg/kg IV

• Preferred in most cases due to better short-term safety profile and option for maintenance treatment 4
• Particularly favored in patients already exposed to immunosuppressives 4
• Consider intensified dosing in patients with low albumin and high disease burden 5

Option 2: Cyclosporine 2 mg/kg IV

• Advantages include rapid onset of action and short half-life 4
• Preferred in patients with imminent risk of colectomy or previous infliximab exposure 4, 5

Assess response to rescue therapy after 4-7 days; if inadequate improvement, proceed to surgery 1

Surgical Indications

Emergency Surgery (Immediate)

Surgery is mandatory for: 3, 1

• Free perforation with generalized peritonitis
• Life-threatening hemorrhage with hemodynamic instability despite resuscitation
• Toxic megacolon complicated by perforation, massive bleeding, clinical deterioration, or signs of shock

Urgent Surgery (Within 24-48 Hours)

Surgery is indicated for: 3, 1

• Toxic megacolon with no clinical improvement after 24-48 hours of medical treatment
• No improvement with second-line rescue therapy after 4-7 days
• Significant recurrent gastrointestinal bleeding

Preferred surgical approach: Subtotal colectomy with ileostomy in the emergency setting 2

Multidisciplinary Management

Joint care by gastroenterologist and colorectal surgeon is essential from admission 1

• Early surgical consultation prevents delayed surgery and associated high morbidity 1
• Patients should be informed of 25-30% chance of needing colectomy 3
• Overall mortality of ASUC is 1%, but significantly higher in patients >60 years with comorbidities 1

Critical Pitfalls to Avoid

• Do not delay corticosteroid treatment while waiting for stool microbiology results 3
• Do not delay surgery in critically ill patients with toxic megacolon, as this increases risk of perforation with high mortality 2
• Do not extend IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery 1
• Do not use corticosteroids for long-term maintenance therapy due to significant adverse effects 2
• Medical rescue therapy should not defer the decision for colectomy in patients with inadequate response 4

Long-Term Maintenance After Acute Episode

Lifelong maintenance therapy is recommended for all patients, particularly those with left-sided or extensive disease 3, 2

• Continue with the agent successful in achieving induction, except corticosteroids 2
• For moderate-to-severe disease requiring biologics, options include infliximab, adalimumab, vedolizumab, ustekinumab, or tofacitinib 2