Acute Severe Colitis

Related Subjects: |Ulcerative Colitis |Acute Severe Colitis |Ischaemic Colitis |Crohn's disease |Coeliac disease

📖 About

• ⚠️ Life-threatening complication of inflammatory bowel disease (UC > Crohn’s). Major risks: toxic megacolon, perforation, sepsis, electrolyte disturbances.
• 🧬 Pathophysiology: severe mucosal inflammation → fluid loss, protein loss, systemic toxicity → haemodynamic compromise.
• 🫀 Systemic features: tachycardia, hypotension, fever, anaemia, hypoproteinaemia.

🧪 Aetiology

• 🔥 Inflammatory bowel disease flare – UC most common; Crohn’s colitis possible.
• 🦠 Pseudomembranous colitis – Clostridioides difficile post-antibiotics.
• 🌍 Infectious colitis – bacterial (Salmonella, Shigella, Campylobacter), parasitic (Giardia, Entamoeba), viral (CMV in immunocompromised).
• 💊 Drug-induced – NSAIDs, immune checkpoint inhibitors, chemotherapeutics.

🩺 Clinical Examination Tips

• 🌡️ Vital signs: fever, tachycardia (>90 bpm), hypotension, postural changes.
• 💩 Abdominal: tenderness, distension, guarding, peritonism (suggests perforation/toxic megacolon).
• 🫀 Hydration status: capillary refill, JVP, orthostatic hypotension, dry mucous membranes.
• ⚡ Red flags: sudden deterioration, severe pain, rising CRP, decreasing Hb/albumin → escalate early.
• 👵 Atypical presentations: elderly or immunosuppressed may have minimal pain, lethargy, confusion, low-grade fever, or subtle diarrhoea.

🔎 Assessment & Investigations

• 🧾 Assess severity with Truelove & Witts criteria (≥6 bloody stools/day + systemic disturbance).
• 📊 Bloods: FBC, U&E, LFTs, Mg, Ca, CRP, glucose, albumin.
• 🧪 Stool: C. difficile PCR/toxin, bacterial culture; consider parasites/CMV in immunocompromised.
• 🩻 Imaging: AXR daily if worsening; CXR to exclude perforation.
• 🧬 Pre-biologic screening: TPMT (azathioprine), QuantiFERON TB, hepatitis B/C serology before Infliximab/Ciclosporin.

🛠️ Initial Management (Day 1–3)

• 💧 IV fluids + correct electrolytes (esp. potassium, magnesium).
• 💊 IV Hydrocortisone 100 mg QDS; monitor response at 72h.
• 🛡️ VTE prophylaxis: LMWH unless contraindicated.
• 🦠 Treat co-existent infections (C. difficile, bacterial, viral).
• ⛔ Stop motility-reducing drugs (opiates, anticholinergics, loperamide).
• 🤝 Early multidisciplinary involvement (Gastro + Surgery).

⚠️ Rescue Therapy (Day 4 if steroid-refractory)

• 💉 Infliximab 5 mg/kg IV (repeat at 2 & 6 weeks, then 8-weekly) – pre-screen for TB/Hep B, monitor LFTs and infection risk.
• 💊 Ciclosporin 2 mg/kg IV – monitor BP, renal function, magnesium; switch to azathioprine for maintenance.
• 🔪 Urgent colectomy – indicated if no response to rescue therapy or if toxic megacolon, perforation, or severe systemic compromise present. Do not delay surgery once criteria met; early intervention improves outcomes.

📏 Truelove & Witts Criteria

🧪 Monitoring

• Daily stool frequency, CRP, haemoglobin, albumin.
• Vital signs at least twice daily; fluid balance strict monitoring.
• AXR daily if distension or worsening clinical status.
• Check for complications: perforation, toxic megacolon, sepsis, shock, electrolyte imbalance.

💡 Exam / Clinical Tips 📝

• 🔹 Mnemonic for ASC severity: “6 BLOOD + SYSTEMIC” – ≥6 stools/day + systemic signs (Fever, Tachycardia, Anaemia, CRP ↑).
• 🔹 Elderly / immunocompromised: watch for subtle signs – confusion, mild diarrhoea, low-grade fever.
• 🔹 Abdominal exam: gently palpate for tenderness, distension, and peritonism; check for rebound.
• 🔹 Pulse >90 bpm, postural hypotension, poor cap refill → early hypovolaemia management.
• 🔹 Daily monitoring: stool chart + fluid balance + vitals → early detection of deterioration.
• 🔹 Labs trend: CRP, Hb, albumin; rising CRP or dropping albumin = poor prognosis.
• 🔹 Early surgical involvement: always involve colorectal team if no improvement by day 3–4.
• 🔹 “Red flag” AXR signs: colonic diameter >6 cm → toxic megacolon; free air → perforation.
• 🔹 Keep teaching aids: visual Truelove & Witts chart, stool frequency log, clinical score card for exams.

💡 Key Teaching Points

• Truelove & Witts criteria define severity; ≥6 bloody stools/day + systemic features = ASC.
• First-line: IV corticosteroids; 1/3 will not respond → escalate at day 4.
• Rescue therapy: infliximab or ciclosporin; surgery if refractory.
• Early surgical input reduces mortality; do not delay colectomy once indicated.
• Atypical presentations common in elderly/immunosuppressed → maintain high suspicion even with subtle symptoms.
• Monitor electrolytes, haemodynamics, and complications throughout admission.

📚 References

• NICE TA163: Infliximab for acute exacerbations of UC
• NICE CG166: Ulcerative colitis: management
• Jain S, et al. 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