In a male patient with ulcerative colitis presenting with tachycardia, left‑shift leukocytosis (20% bands), severe abdominal pain, CT (computed tomography) showing moderate‑to‑severe colitis and ascites, should he be admitted, obtain a GI (gastroenterology) consult, and start IV (intravenous) antibiotics and steroids?

Management of Acute Severe Ulcerative Colitis with Systemic Toxicity

This patient meets criteria for acute severe ulcerative colitis (ASUC) and requires immediate hospital admission, urgent GI consultation, IV corticosteroids (not antibiotics alone), and surgical co-management. 1

Diagnostic Criteria Met

This patient fulfills the modified Truelove and Witts criteria for ASUC with:

• Tachycardia (heart rate >90 bpm) 1
• Left shift with 20% bands indicating systemic toxicity 1
• Severe abdominal pain (a red flag requiring surgical review) 1
• CT evidence of moderate-to-severe colitis with ascites 1

The presence of severe abdominal pain and ascites are particularly concerning features that mandate immediate surgical consultation alongside GI involvement. 1

Immediate Management Algorithm

Day 0 Actions (Within Hours of Presentation):

Admission and Consultations:

• Admit to hospital immediately 1
• Obtain urgent GI consultation 1
• Obtain surgical consultation on Day 0 due to severe abdominal pain and ascites (these features suggest possible complications like impending perforation or toxic megacolon) 1

Baseline Investigations:

• Complete blood count, CRP, urea & electrolytes, liver function tests, magnesium 1
• Stool cultures including C. difficile toxin assay (critical as C. difficile is more prevalent in severe UC and increases mortality) 1
• CT imaging already obtained—review for complications including perforation, toxic megacolon, or abscess 1
• Flexible sigmoidoscopy with biopsies for histology and CMV assessment (can be done urgently or within 24-48 hours) 1

Immediate Treatment (Do Not Delay):

• IV hydrocortisone 100 mg every 6 hours OR IV methylprednisolone 60-80 mg daily 1
• Low molecular weight heparin for thromboprophylaxis 1
• IV fluid resuscitation with potassium supplementation (at least 60 mmol/day to prevent toxic dilatation) 1
• Correct electrolyte abnormalities and anemia 1
• Consider withholding 5-ASA agents 1

Critical Point: Antibiotics Are NOT First-Line Therapy

Antibiotics are NOT routinely indicated for ASUC unless there is documented superinfection (C. difficile, CMV, or bacterial infection). 2 The primary treatment is IV corticosteroids, not antibiotics. 1

Antibiotics should only be added if:

• C. difficile is diagnosed (treat with oral vancomycin 500 mg every 6 hours for 10 days while continuing steroids) 1
• CMV colitis is confirmed on biopsy (treat with IV ganciclovir) 1
• There is evidence of bacterial superinfection or abscess 2
• Perforation or toxic megacolon develops 1

Day 3 Assessment (Critical Decision Point)

Daily monitoring throughout stay includes:

• Senior gastroenterology review 1
• Daily FBC, U&E, CRP 1
• Stool frequency charting 1
• Surgical review if continued systemic toxicity, severe abdominal pain persists, or suspicion of toxic megacolon/perforation 1

Predictors of steroid failure at Day 3:

• 8 bowel movements per day 1

• 3-8 bowel movements per day AND CRP >45 mg/L 1
• These patients have 85% chance of treatment failure and should be considered for rescue therapy (infliximab or ciclosporin) or colectomy 1

Rescue Therapy Considerations

If inadequate response by Day 3-5:

• Infliximab 5 mg/kg IV (at 0,2, and 6 weeks) OR ciclosporin 2 mg/kg/day IV 1
• Both have equivalent efficacy (65-85% initial response) 1, 3
• Surgical review is mandatory before initiating rescue therapy to determine if emergency colectomy is required 1
• Start azathioprine during hospitalization if rescue therapy is used 1

Surgical Indications (Emergency Colectomy)

Absolute indications for immediate surgery:

• Perforation 1
• Massive bleeding with hemodynamic instability 1
• Toxic megacolon with clinical deterioration after 24-48 hours of medical treatment 1
• Progressive deterioration despite maximal medical therapy 1

Relative indications:

• Failure of rescue therapy by Day 7-10 1
• Persistent severe abdominal pain with peritoneal signs 1

Common Pitfalls to Avoid

Do not:

• Delay IV corticosteroids while awaiting stool culture results 1
• Use antibiotics as primary therapy for ASUC without documented infection 2
• Continue ineffective medical therapy beyond 7-10 days (increases morbidity and mortality) 1
• Delay surgical consultation in patients with severe abdominal pain or ascites 1
• Use anticholinergics, antidiarrheals, NSAIDs, or opioids (can precipitate toxic megacolon) 1

The presence of 20% bands, tachycardia, severe pain, and ascites in this patient suggests high risk for complications—joint medical-surgical management from admission is essential. 1