Synopsis
Recognise acute severe ulcerative colitis on admission, deliver a time-critical inpatient bundle, and decide rescue therapy or colectomy before physiological deterioration removes safer options.
- Acute severe ulcerative colitis is conventionally defined by at least six bloody stools daily plus systemic disturbance using Truelove and Witts features; it is a medical and surgical emergency.
- Admit under gastroenterology with colorectal surgical involvement from the start, because early discussion improves planning and does not commit the patient to colectomy.
- Send stool culture and Clostridioides difficile testing, perform blood and abdominal assessment, and undertake careful limited sigmoidoscopy with biopsies for severity and cytomegalovirus when relevant.
Key red flags
Free perforation, peritonism, uncontrolled major haemorrhage or toxic megacolon with deterioration is an indication for emergency surgical management, not further rescue escalation.
Investigation priorities
Track inflammatory burden, bleeding, nutrition, renal perfusion and correction needs.
Management branches
Bloody stool frequency and systemic features meet or strongly suggest acute severe ulcerative colitis.
- Admit to a specialist-capable ward, notify gastroenterology and colorectal surgery, perform ABCDE assessment and document abdominal examination and treatment ceiling.
- Send blood, stool culture and C. difficile tests, obtain an abdominal radiograph and arrange limited sigmoidoscopy with biopsies when stable enough.
Key medicines
Intravenous corticosteroidGive either methylprednisolone 30 mg intravenously every 12 hours or hydrocortisone 100 mg intravenously every 6 hours under the inpatient ASUC protocol. Record response daily and make the formal rescue-or-surgery decision after at least 3 days; higher corticosteroid doses do not add benefit and prolonged ineffective treatment must not delay colectomy.
Infliximab rescueUse infliximab 5 mg/kg by intravenous infusion as specialist rescue after at least 3 days of intravenous corticosteroid without adequate response. Confirm the named product and infusion schedule through the inpatient IBD service; consider intensified dosing only in a selected high-clearance phenotype, particularly low albumin, and do not combine or casually sequence it with ciclosporin.