Should a patient with 20–30 bloody watery stools per day and a C‑reactive protein >300 mg/L be admitted to the hospital?

Immediate Hospital Admission is Mandatory

A patient presenting with 20–30 bloody stools per day and a CRP >300 mg/L meets criteria for acute severe ulcerative colitis (ASUC) and requires immediate hospital admission for intensive medical management and monitoring. 1, 2

Why This Patient Must Be Admitted

This clinical presentation dramatically exceeds the Truelove and Witts criteria for ASUC, which define severe disease as:

• >6 bloody stools per day (this patient has 20–30)
• Plus systemic toxicity markers including CRP >30 mg/L (this patient has >300 mg/L) 1, 2, 3

The British Society of Gastroenterology issues a strong recommendation with 100% consensus that any adult meeting these criteria must be admitted for inpatient care. 2

Immediate Mortality and Morbidity Risks

Life-Threatening Complications

• Toxic megacolon with risk of colonic perforation (mortality 27–57% if perforation occurs) 3
• Massive hemorrhage requiring multiple transfusions 3
• Venous thromboembolism due to severe inflammation and dehydration 1
• Septic shock from bacterial translocation across severely inflamed mucosa 3

Expected Disease Course Without Hospitalization

• 50% of ASUC patients fail to respond to first-line IV corticosteroids and require rescue therapy 2
• 19–23% will require emergency colectomy during the index hospitalization 1, 2
• Overall mortality for ASUC is 1%, but this rises dramatically with delayed treatment or complications 3

Critical Initial Management Required

Immediate Diagnostic Workup (Within Hours of Admission)

• Blood tests: Complete blood count, CRP, urea and electrolytes, liver function tests including albumin 1, 3
• Stool studies: Clostridioides difficile toxin testing (mandatory in every ASUC case) 1, 2
• Flexible sigmoidoscopy: To confirm diagnosis, assess severity, and obtain tissue for CMV immunohistochemistry or PCR 1
• Abdominal imaging: Plain radiograph to exclude toxic megacolon (colon diameter >5.5 cm) 3

First-Line Medical Therapy (Started Immediately)

• IV corticosteroids: Hydrocortisone 100 mg every 6 hours OR methylprednisolone 60 mg once daily 1, 2
• IV fluid resuscitation: Aggressive rehydration to prevent thromboembolism 1
• Thromboprophylaxis: Prophylactic anticoagulation for all hospitalized IBD patients 1
• Pre-biologic screening: Hepatitis B/C, tuberculosis, HIV testing on admission (because 50% will need rescue therapy) 2

Avoid These Common Pitfalls

• Never use opioids or antidiarrheal agents in ASUC—they precipitate toxic megacolon 3
• Do not delay admission for outpatient workup or specialist consultation 2
• Do not wait for stool culture results before starting IV corticosteroids 1

Monitoring Protocol During Hospitalization

Daily Clinical Assessment

• Accurate stool charting: Frequency, consistency, blood content 2, 3
• Vital signs: Temperature, heart rate, blood pressure (looking for sepsis or hypovolemia) 3
• Abdominal examination: Distension, tenderness, peritoneal signs 3
• Serial inflammatory markers: Daily CRP and complete blood count 3
• Serial abdominal radiographs: If clinical deterioration or concern for megacolon 3

Escalation Triggers (Indicating Need for Rescue Therapy)

• No improvement after 3 days of IV corticosteroids (assessed by validated scoring system) 1
• Clinical deterioration at any time: worsening stool frequency, new fever, increasing abdominal pain 3
• Development of complications: Toxic megacolon, massive hemorrhage, perforation 3

When Surgery Becomes Necessary

Absolute Surgical Indications (Emergency Colectomy)

• Colonic perforation 1, 3
• Massive unstable hemorrhage 3
• Clinical deterioration with shock 3

Relative Surgical Indication

• Failure to respond within 7 days of rescue therapy (infliximab or ciclosporin) 1, 3

Critical point: Delay in surgery increases surgical complications—early colorectal surgery consultation is essential. 1

Why Outpatient Management Would Be Catastrophic

With this severity of presentation (20–30 bloody stools, CRP >300 mg/L):

• The patient is at immediate risk of life-threatening complications that require continuous monitoring 2, 3
• Dehydration alone can precipitate venous thromboembolism within 60 days 1
• Approximately 1 in 5 patients with this presentation will need emergency surgery 2
• The patient requires IV medications and fluid resuscitation that cannot be administered outpatient 1, 2