Minireviews
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Sep 27, 2016; 8(9): 598-605
Published online Sep 27, 2016. doi: 10.4240/wjgs.v8.i9.598
Update on medical and surgical options for patients with acute severe ulcerative colitis: What is new?
Rachel E Andrew, Evangelos Messaris
Rachel E Andrew, Evangelos Messaris, Department of Surgery, College of Medicine, the Pennsylvania State University, Hershey, PA 17033-0850, United States
Author contributions: Andrew RE acquired and analyzed the data, and drafted the manuscript; Andrew RE and Messaris E designed the study, interpreted the data and critically revised the manuscript for important intellectual content; Messaris E supervised the study.
Conflict-of-interest statement: We have no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Rachel E Andrew, MD, Department of Surgery, College of Medicine, the Pennsylvania State University, 500 University Drive, Hershey, PA 17033-0850, United States. randrew@hmc.psu.edu
Telephone: +1-717-5315164 Fax: +1-717-5310646
Received: March 29, 2016
Peer-review started: April 5, 2016
First decision: May 23, 2016
Revised: July 14, 2016
Accepted: July 29, 2016
Article in press: August 1, 2016
Published online: September 27, 2016
Processing time: 180 Days and 5.4 Hours
Abstract

Acute severe ulcerative colitis (UC) is a highly morbid condition that requires both medical and surgical management through the collaboration of gastroenterologists and colorectal surgeons. First line treatment for patients presenting with acute severe UC consists of intravenous steroids, but those who do not respond require escalation of therapy or emergent colectomy. The mortality of emergent colectomy has declined significantly in recent decades, but due to the morbidity of this procedure, second line agents such as cyclosporine and infliximab have been used as salvage therapy in an attempt to avoid emergent surgery. Unfortunately, protracted medical therapy has led to patients presenting for surgery in a poorer state of health leading to poorer post-operative outcomes. In this era of multiple medical modalities available in the treatment of acute severe UC, physicians must consider the advantages and disadvantages of prolonged medical therapy in an attempt to avoid surgery. Colectomy remains a mainstay in the treatment of severe ulcerative colitis not responsive to corticosteroids and rescue therapy, and timely referral for surgery allows for improved post-operative outcomes with lower risk of sepsis and improved patient survival. Options for reconstructive surgery include three-stage ileal pouch-anal anastomosis or a modified two-stage procedure that can be performed either open or laparoscopically. The numerous avenues of medical and surgical therapy have allowed for great advances in the treatment of patients with UC. In this era of options, it is important to maintain a global view, utilize biologic therapy when indicated, and then maintain an appropriate threshold for surgery. The purpose of this review is to summarize the growing number of medical and surgical options available in the treatment of acute, severe UC.

Keywords: Acute severe ulcerative colitis; Colectomy; Corticosteroids; Infliximab; Cyclosporine; Ileal pouch-anal anastomosis

Core tip: The numerous avenues of medical and surgical therapy have allowed for great advances in the treatment of patients with ulcerative colitis. In this era of options, it is important to maintain a global view, utilize corticosteroids and rescue therapy when indicated, and then maintain an appropriate threshold for surgery. Colectomy remains a viable and often life-saving treatment and should not be viewed as the “therapy of last resort”.