MANAGEMENT OF ACUTE

SEVERE ULCERATIVE COLITIS

Dr. Anahita Sharma

ST4 Gastroenterology, Royal Blackburn Hospital
 • To generate a differential
diagnosis with regards to the
patient presenting with
acute/acute-on-chronic
diarrhoea.
• To be able to use criteria to
determine the severity of an acute
LEARNING OBJECTIVES
flare of ulcerative colitis as well
as prognosticate response to
steroids.
• To understand how to initiate
appropriate investigations and
treatment for an acute severe flare
of colitis.
• A 36-year old lady presents to A&E
with a 6-week history of increased
stool frequency, associated with
rectal bleeding and mucoid stools.
• She complains of diffuse and
spasmodic abdominal pain associated
with the diarrhoea.
• She states she opens her bowels 6–7
times on each day; prior to last
month, she normally opened them
twice a day.
• She has no recent travel history or
history of trying new foods.
 EXAMINATION (1)

• She appears dehydrated and looks to be in pain.

• Her observations are as follows:
• HR: 105, regular
• BP 130/50
• RR: 18
• T: 37.4°C
• GCS = 15
• Has passed urine whilst in the department
• SpO2: 99% on room air
 EXAMINATION (2)

• On examination of her abdomen, she is markedly

tender over the entire abdomen, but more so on the
left side.
• Her abdomen is distended but there are no signs of
peritonism.
• She cannot tolerate a per rectal examination.
 BLOOD TESTS 💉

• FBC • LFTs, amylase

• Hb 114 g/L • Normal
• WCC 14.0 x 109/L (↑) • CRP
• Platelets 450 x 109/L • 45 mg/dL (↑)
• U&Es • Lactate
• Normal • 2.7 mM (↑)
 • What are your working diagnoses?
• Flare-up of ulcerative colitis (↑ ↑
probability)
• Infectious colitis (↓ probability)
• Crohn's colitis
QUESTIONS (1) • Diverticulitis
• Ischaemic colitis
• Radiation-induced colitis
• Vasculitis
• Drug-induced colitis [which drugs?]
 • Highest prevalence in North America
and Northern Europe, with a
prevalence of 156-291 cases per
100,000 people
• Bi-modal pattern of incidence (mainly
occurs at 15-30 years with a smaller
ULCERATIVE peak at 50-70 years)
COLITIS • Inflammation starts in rectum and
extends proximally
• Crypt disrtortion, crypt abscesses and
plasma-lymphocytoid cell infiltrate in
lamina propria on biopsy
• Risk factors: genetics, previous enteric
infections, environmental factors
 INVESTIGATIONS

• What specific imaging would

you initially request?
• Abdominal X-ray – to exclude
toxic megacolon
• CT abdomen/pelvis – if
suspicion of surgical abdomen
(abscess or perforation), toxic
megacolon
• Any other investigations?
Mayo Scoring:
(A) Score 0=normal; endoscopic remission.
(B) Score 1=mild; erythema, decreased
vascular pattern, mild friability. (C) Score
2=moderate; marked erythema, absent
vascular pattern, friability, erosions.
(D) Score 3=severe; spontaneous bleeding,
ulceration.
 HOW DO YOU
P R O G N O S T I C AT E / D E T E R M I N E
SEVERITY OF THE FLARE?

• Truelove & Witts’ criteria

• Faecal calprotectin (cut-off of
1922.5/g, 87% of patients
underwent colectomy over 1.1
years)
• Biochemical and endoscopic
parameters – CRP >50, albumin
<30 and increased endoscopic
severity predict non-response to
steroids
TRUELOVE &
WITTS’
CRITERIA

N.B. Patients
with IBD will
not always
mount a ‘high’
CRP response
 TREATMENT

• How else would you manage this patient?

• High-dose steroids – IV hydrocortisone 100 mg QDS
• PPI co-prescription not indicated unless ↑ risk of peptic ulcer disease/GI bleed
• Co-prescribe with osteoprotection [consider DEXA if frequent steroid courses]
• Send stool cultures MC&S, incl. C. difficile toxin test [CDI is associated with ↑
mortality] & faecal calprotectin
• IV fluids
• IV antibiotics, if indicated
• Stool chart (give to patient to record output)
• IP flexi-sig [unprepped]
• VTE prophylaxis (pro-thrombotic state ++)
 MANAGEMENT –
GENERAL MEASURES

• How else would you manage

this patient?
• Send biologic screen [HIV, hep
B/C, VZV, TB quantiferon,
TPMT]
• Re-assess progress on day 3
according to Travis Criteria
 Response is defined as a sustained score of
<10 on the modified Truelove & Witts
index

Non-response to steroids at 72 hours is

associated with a high colectomy rate
ASSESSING
RESPONSE • Travis Criteria – if fulfilled, 85% probability of
undergoing emergency colectomy
• If stool frequency >8, or 3-8 stools and CRP >45

Rescue therapy is indicated in non-

responders
 TREATMENT ESCALATION

Ciclosporin (2mg/kg per

day by continuous As per UK-
Infliximab (5mg/kg on infusion for up to 7 CONSTRUCT RCT, no
days 0, 14 and 42) days, then oral therapy difference in outcomes
bd 5.5mg/kg for 12 for these 2 treatments
weeks)

Can be used as a bridge

Accelerated dosing may to thiopurine or
Often agent of choice For patients who are
reduce short-term vedolizumab therapy in
due to ease/familiarity TNF-naïve
colectomy rates patients who are naïve
to thiopurines
 IgG1 monoclonal antibody which targets TNF-α

Standard dose: 5 mg/kg IV at weeks 0, 2, 6 then 8-

weekly

Accelerated dose: 5 mg/kg IV at weeks 0, 1, 3 then

INFLIXIMAB 8-weekly [“antigen sink”, faecal infliximab loss]

Contraindications:
• Congestive cardiac failure [NYHA III/IV]
• Demyelinating disease
• Sepsis or active infection
• Active tuberculosis
 SURGICAL OPTIONS

• Emergency surgery is associated with higher

mortality, morbidity and postoperative infectious
complications
 ↑ LIKELIHOOD OF NEED FOR SURGERY

• Stool frequency > 8/d.

• Pyrexia
• Tachycardia
• Colonic dilatation
• Low albumin / anaemia /
thrombocytosis / raised CRP >45
 TOXIC
MEGACOLON
 MANAGEMENT – MILD-
MODERATE FLARES

• Remission/management of mild-
moderate colitis:
• Topical therapies – 5-aminosalicylates
(mesalazine) or corticosteroid
suppositories
• Oral therapies – 5-aminosalicylates
(avoid steroids due to long-term
effects)
• AZT/mercaptopurine if refractory to 5-
ASAs
• Consideration of biologic therapy (e.g.
infliximab)
 • Always define the extent of
inflammatory bowel disease (i.e.
pancolitis, right- or left-sided, ileo-
caecal, perianal) as this influences
management.
• Steroids may not always be
CROHN’S DISEASE appropriate, particularly if there is
– ADDITIONAL evidence of surgical pathology e.g.
CONSIDERATIONS
perforation.
• In fistulating Crohn’s disease,
further imaging with CT and MRI
of pelvis and rectum may be
required, with possible involvement
of a colorectal surgeon. IBD MDT
involvement is essential.
 ELHT
GUIDELINES
(1)
ELHT GUIDELINES
(2)
ELHT GUIDELINES (3)
ELHT GUIDELINES
(4)
 SOURCES

• Conley TE, Fiske J, Subramanian S How to manage: acute severe colitis

Frontline Gastroenterology 2022;13:64-72.
• Ordas IE et al. Ulcerative Colitis – Seminar. Lancet 2012; 380: 1606-19.
• ELHT Guidelines