Treatment of Ulcerative Colitis

Diagnostic Approach

Disease severity should be classified as mild, moderate, or severe based on clinical parameters, with severe disease defined by 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 for ESR) 1

For proctitis (rectal involvement only), first-line treatment is mesalazine (5-ASA) 1g suppository once daily 1
For mild to moderate left-sided or extensive colitis, first-line treatment is oral mesalazine 2-4g daily, which can be combined with topical mesalazine for better efficacy 2, 3
For moderate to severe colitis, first-line treatment is oral prednisolone combined with mesalazine 2

Subtotal colectomy with ileostomy is the preferred surgical approach in emergency settings 4, 5

Lifelong maintenance therapy is recommended for all patients with ulcerative colitis, particularly those with left-sided or extensive disease 6
Maintenance therapy should continue with the agent successful in achieving induction, except corticosteroids which are not recommended for long-term maintenance 2, 6

Delaying surgery in critically ill patients with toxic megacolon, as this increases the risk of perforation with high mortality 4
Using corticosteroids for long-term maintenance therapy due to significant adverse effects 2, 6

The overall treatment goal has shifted from achieving clinical response to achieving biochemical, endoscopic, and histological remission to prevent long-term disease complications 2

The World Journal of Emergency Surgery recommends administering venous thromboembolism prophylaxis with LMWH as soon as possible due to the high risk of thrombotic events related to complicated IBD 7
The World Journal of Emergency Surgery suggests administering nutritional support (parenteral or enteral, according to GI function) in IBD patients as soon as possible 7
The World Journal of Emergency Surgery advises weaning off steroids (ideally 4 weeks before surgery) and stopping immunomodulators associated with anti-TNF-α agents before surgery to decrease the risk of postoperative complications 7

The World Journal of Emergency Surgery indicates that failure to improve or deterioration within 48-72 hours from initiation of medical therapy in acute severe ulcerative colitis is an indication for surgery 7
The World Journal of Emergency Surgery states that surgical complications such as free perforation, life-threatening hemorrhage, or generalized peritonitis are indications for surgery 7
The World Journal of Emergency Surgery recommends surgery for toxic megacolon complicated by perforation, massive bleeding, clinical deterioration, or signs of shock 7
The World Journal of Emergency Surgery suggests that no response to second-line therapy is an indication for surgery 7

For moderate-to-severe ulcerative colitis, biologic therapy with infliximab, adalimumab, vedolizumab, ustekinumab, or tofacitinib may be considered for patients failing conventional therapy, as suggested by the American Gastroenterological Association 8, 9, 10
The American Gastroenterological Association guidelines suggest ustekinumab or tofacitinib over vedolizumab or adalimumab for patients with prior infliximab exposure, particularly with primary non-response 10
Switching out of class may be reasonable when there is lack of response despite achieving adequate drug concentration, according to the American Gastroenterological Association 8, 9

The ulcerative colitis should be managed independently according to gastroenterology guidelines, with treatment decisions based on disease severity, prior medication exposure, and therapeutic drug monitoring rather than psychiatric medication choices, as recommended by the American Gastroenterological Association and supported by evidence from Gastroenterology and Gut journals 8, 9, 11