Initial Treatment for Acute 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, 2
Severity Assessment and Classification
First, classify disease severity using Truelove and Witts' criteria, which defines severe disease as bloody stool frequency ≥6/day plus at least one of the following: 1
- Tachycardia >90/min
- Temperature >37.8°C
- Hemoglobin <10.5 g/dL
- ESR >30 mm/h (or CRP >30 mg/L)
Perform unprepared flexible sigmoidoscopy with biopsies to confirm diagnosis, assess severity, and exclude cytomegalovirus infection. 1, 2
Treatment Algorithm by Severity
Mild to Moderate Distal Colitis (Proctitis or Left-Sided)
First-line therapy: Topical mesalamine 1 g daily combined with oral mesalamine 2-4 g daily. 1 For proctitis specifically, mesalamine 1g suppository once daily is the preferred initial treatment. 1
If no improvement: Escalate to oral prednisolone 40 mg daily with continued topical agents as adjunctive therapy. 1
Acute Severe Ulcerative Colitis
Immediate IV corticosteroid therapy is mandatory and should not be delayed for screening test results: 1, 2
- Hydrocortisone 100 mg four times daily, OR
- Methylprednisolone 40-60 mg daily
Critical supportive measures include: 2
- IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day to prevent hypokalaemia and toxic dilatation
- Subcutaneous low-molecular-weight heparin for thromboprophylaxis (rectal bleeding is NOT a contraindication)
- Blood transfusion to maintain hemoglobin above 8-10 g/dL
- Withdraw anticholinergic, anti-diarrheal, NSAID, and opioid drugs which may precipitate colonic dilatation
Treatment duration: Limit IV corticosteroids to 7-10 days maximum, as extending beyond this carries no additional benefit. 1, 2
Expected Response and Decision Points
Approximately 67% of patients respond to IV corticosteroids, while 33% require colectomy. 1, 2 Formal assessment of response is required on day 3 to identify patients needing rescue therapy. 2
Monitor closely for signs of progressive deterioration including worsening pain or tenderness, progressive leukocytosis, fever, tachycardia, or hypotension. 3
Rescue Therapy (Days 3-5)
For patients not responding to IV corticosteroids after 3-5 days, two equally effective rescue options exist: 1
- Infliximab 5 mg/kg IV, OR
- Cyclosporine 2 mg/kg IV
The decision for rescue therapy versus surgery should be made by a multidisciplinary team including both gastroenterologist and surgeon. 3
Absolute Surgical Indications
Surgery is mandatory for: 1, 2
- 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 is indicated for: 2
- No improvement with second-line therapy after 4-7 days
- Toxic megacolon with no clinical improvement after 24-48 hours of medical treatment
Critical Pitfalls to Avoid
Do not delay corticosteroid treatment while waiting for stool microbiology results. 1 While stool cultures and Clostridium difficile testing should be obtained (as C. diff is more prevalent in severe UC and associated with increased morbidity), treatment must begin immediately. 2
Do not extend IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery. 1 Prolonged intravenous immunosuppressive therapy is associated with increased morbidity and mortality following subsequent surgery. 3
Do not delay surgery in critically ill patients with toxic megacolon, as this increases risk of perforation with high mortality. 1 Post-operative morbidity is higher after emergency surgery compared with elective surgery, but delay in surgery carries even greater risks. 3
Multidisciplinary Management
Joint care by gastroenterologist and colorectal surgeon from admission is essential, with early surgical consultation preventing delayed surgery and associated high morbidity. 1, 2 Patients should be informed of a 25-30% chance of needing colectomy. 1
Overall mortality of acute severe ulcerative colitis is 1%, but significantly higher in patients >60 years with comorbidities. 1, 2