A 28-year-old with known UC is admitted with 10 bloody stools/day, T 38.2, HR 110, Hb 92, CRP 95. Walk me through inpatient management.

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Accepted Answer

This patient meets **Truelove & Witts criteria for acute severe ulcerative colitis (ASUC)** — ≥6 bloody stools plus tachycardia, fever, and CRP >30. ASUC carries a 1% mortality and a 30% colectomy rate; the management is protocol-driven.

**Initial assessment.** ABCDE, fluid resuscitation, correct anaemia and electrolytes, VTE prophylaxis (LMWH — UC is a prothrombotic state despite the bleeding), nutritional support (avoid NBM unless surgery planned), stop NSAIDs and opioids, stop anti-diarrhoeals (precipitate megacolon).

**Infection screen.** Stool MCS, **C. difficile toxin and PCR**, faecal calprotectin baseline. If steroid-refractory, **flexible sigmoidoscopy with biopsy for CMV** (immunohistochemistry).

**First-line therapy.** **IV hydrocortisone 100 mg QDS** (or methylprednisolone 60 mg IV/24 h). **Topical mesalazine/steroids** are adjunctive.

**Surgical co-management from day 1.** Joint daily review with the colorectal team, mark stoma sites, anaesthetic review — *not* a 'call surgery on day 3' approach.

**Monitoring.** Daily abdominal exam, daily AXR looking for **colonic dilation >5.5 cm (toxic megacolon)**, mucosal islands, small-bowel ileus. Daily CRP, FBC, U&E, albumin.

**Day 3 — the critical decision point (Travis criteria).** CRP >45 mg/L or stool frequency >8/day on day 3 predicts >85% steroid failure. At that point I would:
- Make a clear **rescue decision: ciclosporin 2 mg/kg/24 h IV vs infliximab 5 mg/kg**. CONSTRUCT trial showed equivalence; choice depends on prior thiopurine exposure, comorbidity, and local expertise.
- If **no response within 4–7 days of rescue**, or any sign of toxic megacolon, perforation, or massive bleed at any time, proceed to **subtotal colectomy with end ileostomy**.

**Communication.** Honest conversation with the patient about colectomy as a *good* outcome, not a failure — quality of life often improves. IBD nurse specialist involvement, stoma nurse, mental health support.

**Discharge planning** with maintenance therapy decision (thiopurine, biologic) and IBD MDT follow-up.

Severe acute ulcerative colitis — Truelove & Witts, rescue therapy timelines

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