What is the best next step in management for a female patient with acute severe left-sided ulcerative colitis, presenting with hypotension, tachycardia, bloody diarrhea, low-grade fever, abdominal pain, and joint pain, after fluid resuscitation?

Management of Acute Severe Ulcerative Colitis After Fluid Resuscitation

The best next step is IV methylprednisolone (Option D), as this patient meets criteria for acute severe ulcerative colitis requiring immediate hospitalization and intravenous corticosteroid therapy. 1

Clinical Recognition of Acute Severe Ulcerative Colitis

This patient presents with classic features of acute severe ulcerative colitis (ASUC):

• Truelove and Witts criteria are met: 7-8 bloody stools per day, tachycardia (120/min), fever (37.3°C), anemia (Hb 9 g/L), and markedly elevated ESR (122 mm/h) 1
• Hemodynamic compromise: Hypotension (90/70 mmHg) and tachycardia indicate severe disease requiring urgent intervention 2
• Systemic inflammation: Thrombocytosis (456 × 10⁹/L) and dramatically elevated ESR reflect active severe inflammation 3

ASUC is a potentially life-threatening condition occurring in approximately 20-30% of UC patients during their disease course, with mortality of 1% overall but significantly higher in those with delayed treatment. 1, 3, 4

Why IV Methylprednisolone is the Correct Answer

Intravenous corticosteroids are the first-line treatment for ASUC and should be initiated immediately after fluid resuscitation. 1

Specific Dosing Recommendations:

• IV hydrocortisone 100 mg four times daily OR IV methylprednisolone 30 mg every 12 hours (or 40-60 mg daily) 1, 2
• Methylprednisolone is preferred over hydrocortisone due to less mineralocorticoid effect and lower risk of hypokalemia 2
• Approximately 67% of ASUC patients respond to IV corticosteroids alone 2
• Treatment duration should be limited to 7-10 days maximum, as prolonged courses carry no additional benefit and increase toxicity 2

Critical Supportive Measures to Implement Simultaneously:

• Thromboprophylaxis with low-molecular-weight heparin - rectal bleeding is NOT a contraindication 1, 2
• IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day to prevent hypokalemia and toxic dilatation 2
• Daily monitoring: stool frequency, vital signs, complete blood count, CRP, albumin, and electrolytes 2
• Unprepared flexible sigmoidoscopy to assess severity and exclude CMV colitis 1

Why the Other Options Are Incorrect

Option A: Azathioprine

• Azathioprine has NO role in acute severe colitis 1
• Onset of action is 3-6 months, making it completely inappropriate for acute management 1
• Reserved for maintenance therapy after remission is achieved in steroid-dependent patients 1

Option B: Sulphasalazine

• 5-ASA agents are ineffective in acute severe colitis 1
• Prednisolone is superior to 5-ASA for induction of remission, and this patient requires IV therapy given severity 1
• 5-ASA is appropriate only for mild-to-moderate disease 1, 2

Option C: Oral Budesonide

• Oral budesonide MMX is indicated only for mild-to-moderate UC, not severe disease 1
• This patient's hypotension, tachycardia, and severe laboratory abnormalities mandate parenteral therapy 1, 2
• Budesonide MMX achieves only 17.7% remission rates at 8 weeks in mild-moderate disease 1

Assessment of Treatment Response and Next Steps

Patients must be assessed for clinical and biochemical response after 3-5 days of IV corticosteroids: 1, 2

Predictors of Steroid Failure (indicating need for rescue therapy):

• >8 stools per day OR 3-8 stools per day with CRP >45 mg/L on day 3 predicts 85% colectomy rate 5
• No improvement in stool frequency, persistent fever, or worsening laboratory parameters 2

Rescue Therapy Options (if inadequate response by day 3-5):

• Infliximab 5 mg/kg IV at weeks 0,2, and 6 1, 2, 6
• Ciclosporin 2 mg/kg/day IV 1, 2
• Both are similarly effective and safe; infliximab has become the most widely used salvage therapy 7

Surgical Indications:

• Colectomy is indicated for: failure of rescue therapy after 4-7 days, toxic megacolon without improvement after 24-48 hours, perforation, or massive hemorrhage 1, 5
• Approximately 20-29% of ASUC patients require colectomy during the same admission 2
• Subtotal colectomy with ileostomy is the procedure of choice in the emergency setting 1, 8

Critical Pitfalls to Avoid

• Do NOT delay IV corticosteroids while awaiting stool culture results - infectious causes should be excluded but treatment should not be delayed 5
• Do NOT use anti-diarrheal medications - these can precipitate toxic megacolon 2
• Do NOT continue IV steroids beyond 7-10 days - prolonged courses increase toxicity without benefit 2
• Do NOT delay surgical consultation - joint gastroenterology-surgical management should begin from admission 1, 5