What is the initial treatment approach for a patient presenting with ulcerative colitis?

Initial Treatment of Ulcerative Colitis

The initial treatment approach for ulcerative colitis depends on disease severity and extent: for mild-to-moderate distal disease, start with topical mesalamine 1g daily combined with oral mesalamine 2-4g daily; for acute severe disease, immediately initiate IV corticosteroids (hydrocortisone 100mg four times daily or methylprednisolone 40-60mg daily) without waiting for stool culture results. 1, 2

Disease Severity Classification

• Classify severity using Truelove and Witts' criteria before initiating treatment: severe disease is defined as bloody stool frequency ≥6/day plus at least one of: tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5 g/dl, or ESR >30 mm/h (CRP >30 mg/l can substitute). 1

• Perform unprepared flexible sigmoidoscopy with biopsies to confirm diagnosis, assess severity, and exclude cytomegalovirus infection—do not delay treatment while awaiting results. 1, 2

Treatment Algorithm by Disease Severity and Location

Mild-to-Moderate Proctitis (Rectal Disease Only)

• First-line therapy is mesalamine 1g suppository once daily. 1

• If inadequate response after 2-4 weeks, escalate to combination therapy with oral mesalamine 2-4g daily plus topical mesalamine. 2, 1

Mild-to-Moderate Left-Sided or Extensive Colitis

• Start combination therapy immediately: topical mesalamine 1g daily PLUS oral mesalamine 2-4g daily. 1, 2

• Combination therapy is superior to either topical or oral mesalamine alone and should be the standard approach. 2

• If no improvement after 2-4 weeks on combination mesalamine therapy, add oral prednisolone 40mg daily while continuing topical agents as adjunctive therapy. 2, 1

• Taper prednisolone gradually over 8 weeks according to severity and patient response. 2

Acute Severe Ulcerative Colitis

• Immediately initiate IV hydrocortisone 100mg four times daily OR methylprednisolone 40-60mg daily—do not delay for stool culture results. 1, 3

• Admit patient for intensive monitoring with joint gastroenterology-colorectal surgery management from admission. 1, 2

• Supportive care is critical and includes:

  • IV fluid and electrolyte replacement to correct dehydration 2, 1
  • Blood transfusion to maintain hemoglobin >10 g/dl 2
  • Subcutaneous heparin for thromboembolism prophylaxis 2, 1
  • Nutritional support (enteral or parenteral) if malnourished 2

• Monitor daily: vital signs four times daily, stool chart documenting frequency/character/blood, FBC/CRP/ESR/electrolytes/albumin every 24-48 hours, and daily abdominal radiographs if colonic dilatation (transverse colon >5.5cm) detected. 2, 4

Response Assessment and Treatment Escalation

• Assess response to IV corticosteroids at 3-5 days: patients not responding require rescue therapy or surgery. 1, 3

• Do not extend IV corticosteroids beyond 7-10 days without escalating treatment—this increases surgical morbidity without additional benefit. 1

• For steroid non-responders, two equally effective rescue options exist:

  • Infliximab 5mg/kg IV at weeks 0,2, and 6 1, 5
  • Cyclosporine 2mg/kg IV 1

Surgical Indications

• Absolute indications for emergency surgery include:

  • Free perforation with generalized peritonitis 2, 1
  • Life-threatening hemorrhage with hemodynamic instability despite resuscitation 2, 1
  • Toxic megacolon with no improvement after 24-48 hours of medical treatment 2, 1
  • Clinical deterioration or signs of shock 2

• Subtotal colectomy with ileostomy is the emergency procedure of choice. 2

• Inform patients of 25-30% chance of requiring colectomy during acute severe episodes. 2, 1

Critical Pitfalls to Avoid

• Never delay corticosteroids while awaiting stool microbiology results—acute onset UC is difficult to distinguish from infectious colitis, but treatment must not be delayed. 1, 2

• Never delay surgery in critically ill patients with toxic megacolon—mortality is significantly higher with delayed surgery, particularly in patients >60 years. 1, 4

• Do not use topical corticosteroids as first-line therapy for distal disease—they are less effective than topical mesalamine and should be reserved as second-line therapy for patients intolerant of topical mesalamine. 2

• Maintain low threshold for repeat abdominal radiographs if any clinical deterioration occurs, even if initial imaging was normal. 4

Maintenance Therapy After Remission Induction

• Lifelong maintenance therapy is recommended for all patients, especially those with left-sided or extensive disease. 2, 1

• Continue with the agent successful in achieving induction (except corticosteroids). 1

• For patients requiring biologics during acute phase, maintenance options include infliximab, adalimumab, vedolizumab, ustekinumab, or tofacitinib. 1, 6