Management of acute severe ulcerative colitis

Abstract

The management strategy of acute severe ulcerative colitis has evolved over the past decade from being entirely restricted to twin choices of intravenous steroids or colectomy to include colon rescue therapies like cyclosporin as well as infliximab. However it still remains a medical emergency requiring hospitalization and requires care from a multidisciplinary team comprising of a gastroenterologist and a colorectal surgeon. The frame shift in management has been the emphasis on time bound decision making with an attempt to curtail the mortality rate to below 1%. Intravenous corticosteroids are the mainstay of therapy. Response to steroids should be assessed at day 3 of admission and partial/non-responders should be considered for alternative medical therapy/surgery. Medical rescue therapies include intravenous cyclosporin and infliximab. Cyclosporin is administered in a dose of 2 mg/kg per day and infliximab is administered as a single dose intravenous infusion of 5 mg/kg. Approximately 75% patients have short term and 50% patients have long term response to cyclosporin. Long term response to cyclosporin is improved in patients who are thiopurine naïve and are started on thiopurines on day 7. Infliximab also has a response rate of approximately 70% in short term and 50% in long term. Both cyclosporin and infliximab are equally efficacious medical rescue therapies as demonstrated in a recent randomized control trial. Patients not responding to infliximab or cyclosporin should be considered for colectomy.

Keywords: Ulcerative colitis, Acute severe colitis, Intravenous steroids, Cyclosporin, Infliximab

Core tip: The mortality of severe ulcerative colitis has drastically reduced from 30%-60% in pre steroid era to 1%-2.9% at present. However these figures are for specialist centers and at peripheral centers the mortality figures may be higher. The objective of this review is to provide in depth information for what can be categorized as a gastrointestinal medical emergency with the hope that informed clinical practices may translate to superior patient care at tertiary as well as peripheral centers treating ulcerative colitis. This review provides time bound framework, which looks at stepwise management of acute severe ulcerative colitis and explores the recent concepts of choice between biologics and cyclosporin colon rescue therapies in case of steroid refractory disease.