Treatment of Acute Onset Ulcerative Colitis

Initial Assessment and Management

The American Gastroenterological Association recommends classifying disease severity using Truelove and Witts' criteria, which defines severe disease as bloody stool frequency ≥6/day plus at least one of: tachycardia >90/min, temperature >37.8°C, hemoglobin <10.5 g/dl, or ESR >30 mm/h (CRP >30 mg/l can substitute) 2
For acute severe ulcerative colitis, the European Crohn’s and Colitis Organisation recommends immediately initiating intravenous corticosteroids (hydrocortisone 100 mg four times daily or methylprednisolone 40-60 mg daily) along with aggressive supportive care, without waiting for stool culture results 1
The American College of Gastroenterology suggests performing unprepared flexible sigmoidoscopy with biopsies to confirm diagnosis, assess severity, and exclude cytomegalovirus infection 1

For mild to moderate distal UC (proctitis or left-sided), the American Gastroenterological Association recommends first-line therapy with topical mesalamine 1 g daily combined with oral mesalamine 2-4 g daily 3, 2
The European Crohn’s and Colitis Organisation recommends that for proctitis specifically, mesalamine 1g suppository once daily is first-line 2
If no improvement on combination therapy, the American College of Gastroenterology suggests escalating to oral prednisolone 40 mg daily with continued topical agents as adjunctive therapy 3

The American Gastroenterological Association recommends starting IV hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily immediately, without delaying for screening test results 1
Treatment duration should be limited to 7-10 days maximum, as extending beyond this carries no additional benefit 1
The European Crohn’s and Colitis Organisation suggests that overall response rate to IV corticosteroids is 67%, with 33% requiring colectomy 1

For patients not responding to IV corticosteroids after 3-5 days, the American College of Gastroenterology recommends two equally effective rescue options: infliximab 5 mg/kg IV or cyclosporine 2 mg/kg IV 1

The World Journal of Emergency Surgery recommends that surgery is mandatory for free perforation with generalized peritonitis, life-threatening hemorrhage with hemodynamic instability despite resuscitation, and toxic megacolon complicated by perforation, massive bleeding, clinical deterioration, or signs of shock 4, 1
The American Gastroenterological Association suggests that surgery is indicated for toxic megacolon with no clinical improvement after 24-48 hours of medical treatment and significant recurrent gastrointestinal bleeding 4, 1

The American College of Gastroenterology recommends joint care by gastroenterologist and colorectal surgeon from admission, with early surgical consultation to prevent delayed surgery and associated high morbidity 1
Patients should be informed of 25-30% chance of needing colectomy 3
Overall mortality of ASUC is 1%, but significantly higher in patients >60 years with comorbidities 1

The European Crohn’s and Colitis Organisation recommends not delaying corticosteroid treatment while waiting for stool microbiology results 3
The American Gastroenterological Association suggests not delaying surgery in critically ill patients with toxic megacolon, as this increases risk of perforation with high mortality 2
The American College of Gastroenterology recommends not extending IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery 1

The American Gastroenterological Association recommends lifelong maintenance therapy for all patients, particularly those with left-sided or extensive disease 3, 2
Continue with the agent successful in achieving induction, except corticosteroids 2
For moderate-to-severe disease requiring biologics, options include infliximab, adalimumab, vedolizumab, ustekinumab, or tofacitinib 2