What is the most appropriate management for a patient with ulcerative colitis (UC) presenting with abdominal pain, bloody diarrhea, vomiting, dehydration, and leukocytosis?

Management of Acute Severe Ulcerative Colitis with Toxic Megacolon

This patient requires immediate total colectomy with end ileostomy (Option D) due to toxic megacolon, which is a surgical emergency that carries high mortality risk if managed medically. 1, 2

Clinical Recognition of Toxic Megacolon

This patient presents with the classic triad indicating toxic megacolon:

• Radiographic evidence: Dilated transverse colon (>5.5 cm) with loss of haustrations on plain abdominal X-ray 3
• Systemic toxicity: Leukocytosis (WBC elevated), dehydration, distended abdomen 1, 2
• Severe colitis symptoms: Bloody diarrhea, vomiting, abdominal tenderness with sluggish bowel sounds 3, 4

The combination of colonic dilatation with systemic toxicity represents a life-threatening complication requiring urgent surgical intervention. 1, 2

Why Medical Management is Contraindicated

High-dose systemic steroids (Option A) and infliximab (Option B) are absolutely contraindicated in established toxic megacolon because:

• Medical therapy delays definitive treatment and increases mortality risk 1, 2
• Continuing immunosuppression in the setting of impending perforation dramatically worsens outcomes 3, 4
• The European Crohn's and Colitis Organisation explicitly states that emergency surgery is indicated for toxic megacolon 5
• Approximately 20-29% of acute severe UC patients require colectomy during admission, but this percentage is much higher with toxic megacolon 1

While IV corticosteroids (40-60 mg methylprednisolone daily) are first-line for acute severe UC without toxic megacolon 3, and rescue therapy with infliximab 5 mg/kg or ciclosporin 2 mg/kg/day is appropriate for steroid-refractory disease 1, 2, these medical options are only considered when there is no colonic dilatation or impending perforation. 3, 4

Surgical Approach

Total colectomy with end ileostomy is the procedure of choice rather than proctocolectomy with ileal pouch (Option C) because:

• In the emergency/toxic setting, a single-stage procedure minimizes operative time and physiologic stress 5
• The patient is systemically unwell (dehydrated, toxic), making complex reconstructive surgery inappropriate 3, 1
• End ileostomy can be performed quickly and safely, with potential for future pouch construction once the patient recovers 5
• Proctocolectomy with immediate pouch construction carries unacceptably high complication rates in the acute toxic setting 3

Critical Management Principles

Immediate preoperative stabilization (while arranging urgent surgery):

• IV fluid and electrolyte replacement with potassium supplementation ≥60 mmol/day to prevent worsening dilatation 3, 2
• Low-molecular-weight heparin for thromboprophylaxis (rectal bleeding is NOT a contraindication) 3, 5
• Broad-spectrum antibiotics to cover potential translocation from dilated, ischemic bowel 3
• Avoid anti-diarrheal medications which can precipitate or worsen toxic megacolon 1, 5

Joint gastroenterology-surgical management from admission is essential, with patients informed of the 25-30% baseline colectomy risk in severe UC, which approaches 100% with established toxic megacolon. 3, 2

Common Pitfalls to Avoid

• Never delay surgery while attempting medical rescue therapy in the presence of colonic dilatation >5.5 cm 1, 2, 5
• Never continue IV corticosteroids beyond 7-10 days in severe UC without toxic megacolon, but with toxic megacolon, surgery should not be delayed even 24 hours 3, 5
• Never perform complex reconstructive surgery (ileal pouch) in the acute toxic setting 3, 5

The overall mortality of acute severe UC is 1%, but rises significantly in patients >60 years and those with toxic megacolon if surgery is delayed. 3, 1