What is the best course of treatment for a patient with ulcerative colitis (UC) experiencing uncontrolled bleeding that is not stopping?

Management of Uncontrolled Bleeding in Ulcerative Colitis

If the patient is hemodynamically unstable with ongoing massive hemorrhage, proceed immediately to emergency subtotal colectomy with ileostomy without delay—this is the definitive life-saving intervention. 1

Immediate Assessment: Hemodynamic Status Determines Everything

Your first priority is determining hemodynamic stability, as this dictates whether you proceed directly to the operating room or have time for diagnostic evaluation:

Hemodynamically Unstable Patients (Hemorrhagic Shock):

• Immediate emergency surgery is mandatory without attempting further medical therapy or diagnostic procedures 1
• Subtotal colectomy with end ileostomy is the procedure of choice 1, 2
• Open surgical approach is recommended to minimize operative time in unstable patients 1
• The critical pitfall here is delaying surgery while attempting additional medical resuscitation or endoscopic intervention—this substantially increases mortality 3, 4

Hemodynamically Stable After Resuscitation:

• Proceed with diagnostic evaluation while preparing for potential surgery 1
• Perform flexible sigmoidoscopy and esophagogastroduodenoscopy to localize bleeding source and exclude upper GI or anorectal sources 1
• Obtain CT angiography if ongoing bleeding persists after initial resuscitation 1
• Initiate aggressive medical management while monitoring closely for deterioration 2

Medical Management for Stable Patients

While evaluating stable patients with severe bleeding, implement the following simultaneously:

Immediate Supportive Measures:

• Start intravenous corticosteroids immediately (hydrocortisone 100 mg IV four times daily OR methylprednisolone 40-60 mg IV daily) 2
• Administer subcutaneous low-molecular-weight heparin for thromboprophylaxis—rectal bleeding is NOT a contraindication 2
• Provide aggressive IV fluid resuscitation with electrolyte replacement, ensuring potassium supplementation of at least 60 mmol/day 2
• Obtain stool cultures and Clostridium difficile testing, but do not delay corticosteroid treatment while awaiting results 2

Escalation to Rescue Therapy:

• If no improvement within 3-5 days of IV corticosteroids, escalate to rescue medical therapy with infliximab (5 mg/kg at weeks 0,2,6) or cyclosporine 5, 6, 7
• Do not extend IV corticosteroids beyond 7-10 days without escalating therapy or proceeding to surgery 2
• Infliximab has demonstrated 62-69% clinical response rates at week 8 in acute severe UC 8

Surgical Indications: When Medical Management Fails

Absolute Indications for Emergency Surgery:

• Persistent hemodynamic instability despite resuscitation with ongoing massive hemorrhage 1
• Colonic perforation with generalized peritonitis 1, 2
• Toxic megacolon complicated by perforation, massive bleeding, or clinical deterioration with shock 1, 3
• Radiological signs of pneumoperitoneum with free fluid in an acutely unwell patient 1

Urgent Surgical Indications:

• Refractory hemorrhage in acute severe UC non-responsive to medical treatment after 48-72 hours 1, 2
• Toxic megacolon without improvement after 24-48 hours of aggressive medical treatment 1, 3
• Significant recurrent gastrointestinal bleeding despite medical therapy 1
• Clinical deterioration or failure to improve within 48-72 hours of initiating medical therapy 1, 2

Surgical Procedure

Subtotal colectomy with end ileostomy is the definitive procedure for acute severe UC with massive hemorrhage or medical treatment failure 1, 2:

• This involves removal of the colon with creation of an end ileostomy 3
• Laparoscopic approach may be considered in hemodynamically stable patients with appropriate surgical expertise 1
• Open approach is mandatory for unstable patients or those with generalized peritonitis 1, 4
• In patients with severe sepsis or shock, apply damage control principles with resection and temporary closure, returning to OR in 24-48 hours 1, 4

Critical Pitfalls to Avoid

The most dangerous error is delaying surgery while attempting additional medical therapy in a patient with massive hemorrhage who has already failed initial medical treatment—this substantially increases mortality risk 3, 4, 2. Surgery should not be delayed beyond 48-72 hours if there is no clinical improvement, as prolonged observation increases perforation risk and mortality 3, 4.

Multidisciplinary Approach

• Involve colorectal surgery from the time of admission for all patients with severe bleeding 5, 7
• Discuss surgical options early with the patient as one of the therapeutic alternatives 5
• Coordinate care between gastroenterology and surgery to ensure timely intervention when medical therapy fails 5, 7