Makindo Medical Notes

💊 Treat with high-dose IV steroids for 3 days and then decide if rescue therapy such as Infliximab, Ciclosporin, or Colectomy is needed. 🚨 Early escalation saves lives.

⚡ Initial Management Summary for Acute Severe Colitis

🧾 Assess severity using Truelove and Witts criteria. 💧 Give IV fluids, correct electrolytes (esp. potassium), and provide VTE prophylaxis. 💉 IV Hydrocortisone 100 mg QDS for 3 days → review response. (PO steroids for milder disease). 🦠 Test for & treat C. difficile infection if present. ⛔ Stop drugs that slow motility (opiates, anticholinergics, loperamide). 📸 Repeat AXR/CT if worsening to exclude perforation or toxic megacolon. 🤝 Liaise early with colorectal + GI teams. 📅 On Day 4 → make joint decision on rescue therapy (Infliximab / Ciclosporin / Surgery).

📖 About

• ⚠️ Acute severe colitis (ASC) is a life-threatening complication of ulcerative colitis.
• Major risks: toxic megacolon, perforation, sepsis.
• Pathophysiology: inflamed mucosa loses absorptive capacity → diarrhoea, bleeding, protein loss, and systemic illness.

🧑‍⚕️ Clinical

• 🌡️ Fever, malaise, anorexia.
• 💩 Frequent bloody diarrhoea ± mucus, pus.
• ⚡ Abdominal pain, tenderness, distension.
• 🫀 Tachycardia (↑ 30 bpm on sitting suggests hypovolaemia).
• ⬇️ JVP, poor cap refill, postural hypotension.

🔎 Causes

• 🔥 Inflammatory bowel disease (UC > Crohn’s) – acute flare.
• 🦠 Pseudomembranous colitis → C. difficile (recent antibiotics).
• 🌍 Infectious colitis (travel, HIV, typhoid, amoebiasis).
• 💊 Drug-induced colitis (NSAIDs, immunotherapy).

🗺️ Extent of Ulcerative Colitis

🚨 Clinical Features of Acute Severe Colitis

• Often toxic, feverish, dehydrated, unwell.
• 💉 Rectal bleeding, diarrhoea, tenesmus.
• ⚡ Abdominal cramps, distension, guarding, peritonism.
• Signs of shock if perforated.

❓ Key Questions

• 💩 Number of bowel motions per day?
• 🩸 Blood in stools?
• 🌡️ Pyrexia?
• 🫀 Pulse > 90 bpm?
• 🧪 ESR or CRP elevated?
• 🩺 Haemoglobin level?

🔬 Investigations

• 📊 FBC, U&E, LFTs, Mg, Ca, CRP, glucose.
• 🧪 Stool: C. difficile, Salmonella, Shigella, Campylobacter, E. coli.
• 🌍 Immunocompromised → Giardia, Crypto, Isospora, CMV.
• 🩻 AXR daily if worsening (look for megacolon, perforation).
• 🫁 CXR to exclude perforation.
• TPMT if Azathioprine likely; QuantiFERON if biologics planned.

📏 Truelove and Witts Criteria

Parameter	Mild	Moderate	Severe
Bloody stools/day	<4	4–6	>6
Temperature	Afebrile	-	>37.8 °C
Heart rate	Normal	-	>90 bpm
Haemoglobin	>11 g/dL	10.5–11	<10.5
ESR	<20	20–30	>30

🛠️ Management of Acute Severe Colitis

• 🔎 Assess severity with Truelove & Witts.
• 📉 Day 3: Stool freq > 8/day or CRP > 45 → 85% colectomy risk.
• 💉 1st-line: IV corticosteroids → but 1/3 won’t respond.
• 📅 Day 4: If no improvement → escalate to rescue therapy.
• ⚠️ Monitor for megacolon or perforation.

🛑 Rescue Therapy

• 💉 Infliximab 5 mg/kg IV – repeat at 2 & 6 weeks, then 8-weekly (check TB, Hep B).
• 💊 Ciclosporin 2 mg/kg IV – monitor Mg & cholesterol, switch to Azathioprine later.
• 🔪 Colectomy – if failed medical therapy; delay worsens prognosis.

📚 References

• Jain S, Ahuja V, Limdi JK. Optimal management of acute severe ulcerative colitis. Postgrad Med J 2019;95:32-40.
• Jakobovits SL, Travis SPL. Management of acute severe colitis. Br Med Bull 2005;75-76:131-144.
• NICE: Infliximab for acute exacerbations of UC.
• Dr Benjamin Cohen: Updates in Acute Severe UC (YouTube)

Cases — IBD: Acute Severe Colitis (ASC)

• Case 1 — Ulcerative Colitis Flare 🧻: A 26-year-old man with known ulcerative colitis presents with 12 bloody diarrhoeal stools/day, fever, and abdominal pain. Exam: tachycardia 120, tender but not peritonitic abdomen. CRP 120, Hb 95 g/L, albumin 28. AXR: no toxic megacolon. Diagnosis: Acute severe ulcerative colitis flare. Management: Admit, IV hydrocortisone 100 mg qds, IV fluids, VTE prophylaxis, stool cultures incl. C. difficile. If no improvement by day 3 → escalate (ciclosporin or infliximab).
• Case 2 — Fulminant Colitis with Toxic Megacolon ⚠️: A 32-year-old woman presents with worsening UC flare: 15 bloody stools/day, fever, severe abdominal distension. Exam: peritonism, HR 130. AXR: dilated transverse colon 7.5 cm. Diagnosis: Toxic megacolon complicating acute severe UC. Management: Resuscitation, IV steroids, antibiotics, urgent surgical (subtotal colectomy with ileostomy) referral.
• Case 3 — Crohn’s Disease Acute Colitis 🌿: A 40-year-old man with Crohn’s colitis presents with >10 bloody diarrhoeas/day, abdominal pain, fever. Exam: tender colon, HR 115, BP 95/60. CRP 150. CT abdomen: diffuse colitis, no perforation. Diagnosis: Acute severe colitis due to Crohn’s disease. Management: IV hydrocortisone; screen for TB/hepatitis prior to rescue biologics; MDT input with gastro + surgeons; early escalation to infliximab if steroid-refractory.

Teaching Commentary 🧠

Acute severe colitis = life-threatening flare of IBD (commonly UC, sometimes Crohn’s). Truelove & Witts criteria (for UC): ≥6 bloody stools/day + systemic disturbance (HR >90, T >37.8°C, Hb <105, CRP >30). ⚡ Management = “IV steroids, fluids, VTE prophylaxis, stool cultures, surgical backup”. If no improvement at day 3 → “rescue therapy” (ciclosporin or infliximab) or urgent colectomy. Complications: toxic megacolon, perforation, sepsis. Always involve surgeons early — mortality is much lower with timely colectomy than delayed intervention.