USMLE Prep - Medical Reference Library

Acute Severe Ulcerative Colitis — IV Steroids, Rescue Therapy, and Colectomy Triggers

System: Gastroenterology • Reviewed: Aug 31, 2025 • Step 1Step 2Step 3

Synopsis:

Hospitalize for intensive monitoring, start IV corticosteroids, perform early flexible sigmoidoscopy, and escalate to infliximab or cyclosporine if steroid-refractory; coordinate with colorectal surgery for timely colectomy when failure criteria are met.

Key Points

  • Stabilize ABCs; treat life‑threatening derangements immediately.
  • Confirm diagnosis early with highest‑yield imaging/labs.
  • Initiate guideline‑based therapy and escalate by response.
  • Plan disposition and follow‑up explicitly.

Clinical Synopsis & Reasoning

ASUC requires hospitalization, IV steroids (e.g., methylprednisolone 60 mg daily), early flexible sigmoidoscopy, and VTE prophylaxis. Use day‑3 response to decide on rescue therapy (infliximab or cyclosporine). Failure or complications such as toxic megacolon or perforation mandate urgent surgical consultation for subtotal colectomy.

Treatment Strategy & Disposition

ASUC requires hospitalization, IV steroids (e.g., methylprednisolone 60 mg daily), early flexible sigmoidoscopy, and VTE prophylaxis. Use day‑3 response to decide on rescue therapy (infliximab or cyclosporine). Failure or complications such as toxic megacolon or perforation mandate urgent surgical consultation for subtotal colectomy.

Epidemiology / Risk Factors

  • Risk varies by comorbidity and precipitating factors

Initial Targets

ParameterTarget/Action
HemodynamicsMaintain perfusion; avoid hypotension
MonitoringSerial exam, labs, and imaging
TherapyStart early, reassess, de‑escalate when appropriate

Investigations

TestRole / RationaleTypical FindingsNotes
CBCScreen leukocytosis/anemiaContext‑specificTrend response
BMPElectrolytes/renal functionDerangements commonReplace K+/Mg2+
Key imagingCondition‑specific (CTA/MRI/Endoscopy)See textDo not delay when red flags

Pharmacology

MedicationMechanismOnsetRole in TherapyLimitations
Methylprednisolone 60 mg IV dailyGlucocorticoidHoursFirst‑lineHyperglycemia, infection
Infliximab (rescue)Anti‑TNFHours–daysSteroid‑refractoryTB/hep B screen
Cyclosporine (alternative)Calcineurin inhibitorHours–daysRescue optionNephrotoxicity

Prognosis / Complications

  • Outcome depends on timeliness of diagnosis and definitive therapy

Patient Education / Counseling

  • Explain red flags, adherence, and follow‑up plan

References

  1. ECCO UC Therapeutics (2022/2023) — Link
  2. AGA Moderate-to-Severe UC Guideline (2020) — Link