Acute severe ulcerative colitis — Rapid

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.
Start intravenous corticosteroid promptly after cultures, while providing fluids, electrolyte correction, nutrition, pharmacological thromboprophylaxis and avoidance of antimotility medicines and unnecessary opioids.
Record stool number and blood, observations, abdominal signs, CRP, blood count, albumin and renal function daily; vague better or worse language is unsafe.
At day three, more than 8 bowel movements daily, or 3–8 daily with CRP above 45 mg/L, predicts a high risk of corticosteroid failure; make the multidisciplinary decision between rescue infliximab, rescue ciclosporin and colectomy without delay.
Do not give sequential rescue therapies casually because cumulative immunosuppression can increase infection and delay surgery; exceptional use belongs in a highly experienced service.
Perforation, uncontrolled haemorrhage, toxic megacolon or continuing deterioration despite optimal rescue requires urgent colectomy rather than repeated medical delay.

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.

Reduced stool frequency with increasing distension and systemic toxicity can mean colonic paralysis rather than improvement.

Do not delay colectomy because CRP temporarily falls if pain, tenderness, dilatation, haemodynamics or organ function are worsening.

Fever, shock or new organ dysfunction during combined immunosuppression requires immediate sepsis assessment and source control.

Hypokalaemia, hypomagnesaemia, anaemia and malnutrition amplify ileus, arrhythmia and operative risk and require active correction.

Investigation priorities

Daily full blood count, CRP, albumin, renal and electrolyte profileFirst step

Track inflammatory burden, bleeding, nutrition, renal perfusion and correction needs.

Management branches

ADMITDeliver the first-day bundle

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.
Begin protocolised intravenous corticosteroid, fluids and electrolyte correction, nutrition assessment and pharmacological venous-thromboembolism prophylaxis unless a true contraindication exists.
Stop antimotility drugs, unnecessary NSAIDs and avoid escalating opioids; treat proven infection and provide clear daily multidisciplinary review.

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.Check glucose, mental state and infection; benefit should be judged by day three and treatment must not continue ineffectively while surgery is delayed.

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.Avoid uncontrolled sepsis; low albumin and high inflammatory clearance may affect exposure, while tuberculosis, hepatitis, infusion reaction and postoperative infection risk require specialist judgement.

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