Inflammatory bowel disease - Acute Severe Colitis
💊 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 |
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- 🧾 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).
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📖 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
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.
