What is the best next step in management for a female patient with left-sided ulcerative colitis, presenting with severe symptoms including hypotension, tachycardia, anemia, and elevated erythrocyte sedimentation rate (ESR), after fluid resuscitation?

Management of Acute Severe Ulcerative Colitis

This patient requires immediate IV methylprednisolone (Option D) as the first-line treatment for acute severe ulcerative colitis after fluid resuscitation. 1, 2

Disease Severity Classification

This patient meets criteria for acute severe ulcerative colitis based on the Truelove and Witts criteria, which requires bloody stool frequency ≥6/day plus at least one additional criterion 1:

• 7-8 bloody stools/day (meets frequency threshold)
• Tachycardia (HR 120/min, >90/min required)
• Anemia (Hb 9 g/L, <10.5 g/dL required)
• Markedly elevated ESR (122 mm/h, >30 mm/h required)
• Hypotension (BP 90/70 mmHg, indicating hemodynamic instability)
• Low-grade fever (37.3°C)

The presence of multiple criteria beyond the minimum confirms this is severe disease requiring hospitalization and aggressive medical management. 1

Why IV Methylprednisolone is the Correct Answer

Intravenous corticosteroids are the established first-line treatment for acute severe UC in hemodynamically stable patients after fluid resuscitation. 1, 2 The British Society of Gastroenterology specifically recommends either hydrocortisone 100 mg four times daily or methylprednisolone 30 mg every 12 hours (or 40-60 mg/day), with methylprednisolone preferred due to less mineralocorticoid effect and lower risk of hypokalemia. 2

Approximately 67% of patients with acute severe UC respond to IV corticosteroids alone, making this the appropriate initial therapy. 2 Response should be assessed by day 3-5, and if inadequate, rescue therapy with infliximab (5 mg/kg) or cyclosporin (2 mg/kg/day) should be considered. 1, 2

Why the Other Options Are Incorrect

Option A: Azathioprine

• Azathioprine is a maintenance therapy that takes 3-4 months to achieve therapeutic effect 1
• It has no role in acute severe disease and would be considered only after remission is induced with corticosteroids or biologics 1
• This patient requires immediate disease control, not long-term immunomodulation

Option B: Sulphasalazine

• 5-ASA agents (including sulphasalazine) are ineffective for acute severe UC 1
• These are appropriate only for mild-to-moderate disease 1
• The British Society of Gastroenterology explicitly states that patients with severe UC require corticosteroids, not 5-ASA escalation 1

Option C: Oral Budesonide

• Budesonide MMX is indicated only for mild-to-moderate UC, not severe disease 1
• The CORE I and CORE II trials demonstrated efficacy in mild-to-moderate left-sided and extensive UC, with week 8 remission rates of only 17.7% 1
• This patient's severe presentation with hemodynamic instability requires systemic IV corticosteroids, not topically-acting oral formulations 1, 2

Critical Management Algorithm After IV Corticosteroids

1. Supportive care alongside IV methylprednisolone 1, 2:

   • IV fluid and electrolyte replacement with potassium supplementation ≥60 mmol/day 2
   • Low-molecular-weight heparin for thromboprophylaxis (rectal bleeding is NOT a contraindication) 2
   • Nutritional support if malnourished 1

2. Daily monitoring 2:

   • Stool frequency, vital signs
   • Complete blood count, CRP, albumin, electrolytes
   • Clinical assessment for peritoneal signs

3. Assessment at day 3-5 1, 2:

   • If inadequate response: consider rescue therapy with infliximab 5 mg/kg or cyclosporin 2 mg/kg/day 1, 2
   • Treatment duration with IV corticosteroids should be limited to 7-10 days maximum, as prolonged courses increase toxicity without additional benefit 2

4. Surgical consultation 1, 3:

   • Approximately 20-29% of acute severe UC patients require colectomy during the same admission 2
   • Emergency colectomy indicated for: refractory toxic megacolon, perforation, severe hemorrhage, or failure of medical rescue therapy after 4-7 days 3

Important Caveats

• This patient's hypotension must be corrected with fluid resuscitation BEFORE initiating corticosteroids, as stated in the question stem 1
• Avoid anti-diarrheal medications as they increase risk of toxic megacolon 2
• Stool cultures were negative, appropriately excluding infectious causes before immunosuppression 1
• Overall mortality of acute severe UC is 1%, but significantly higher in patients >60 years or with comorbidities 2
• The joint pain (arthralgia) represents an extra-intestinal manifestation that typically improves with control of the underlying colitis 1