Acute Severe Ulcerative Colitis

Truelove & Witts: ≥6 bloody stools/day + any systemic feature = ASUC — a medical emergency. Day-1: IV hydrocortisone, LMWH, stool cultures + C. diff, AXR, surgical alert. Day-3 Oxford Index decides rescue therapy. Colon >6cm + toxicity = toxic…

ASUC Pathway (Truelove & Witts → Oxford Index)

The pathway

1 · Score severity

≥6 bloody stools/day PLUS any of: HR >90, T >37.8, Hb <105, CRP/ESR raised
~1% mortality — admit

2 · Day-1 bundle

IV hydrocortisone 100mg QDS
LMWH VTE prophylaxis — bloody stool is NOT a contraindication
Stool cultures + C. diff toxin
AXR for dilatation

3 · Stop the dangerous

Stop opioids, antimotility agents, NSAIDs
All increase megacolon risk

4 · Involve teams early

Gastroenterology — limited unprepped flexible sigmoidoscopy
Alert colorectal surgeons on day 1, not day 5

5 · Day-3 Oxford Index

>8 stools/day, OR 3–8 stools + CRP >45 = 85% colectomy risk
Decide rescue therapy that day

6 · Rescue or surgery

Infliximab or ciclosporin (screen TB/HBV/HIV)
Joint decision with surgeons
Azathioprine is far too slow

7 · Watch for megacolon

Colon >6cm + toxicity
NBM, NG, correct K⁺, antibiotics
Emergency subtotal colectomy — timely surgery saves lives

Drugs

Drug	Dose	Route	Notes
Hydrocortisone	100mg QDS	IV	First-line. Or methylprednisolone 60mg/day.
Enoxaparin	Prophylactic dose	SC	Give it — ASUC is highly prothrombotic despite bleeding.
Infliximab	5mg/kg	IV	Rescue therapy. Screen TB/HBV/HIV where time allows.
Ciclosporin	2mg/kg/day	IV	Alternative rescue. Monitor levels, BP, renal function, magnesium.

When to escalate

Meeting Truelove & Witts criteria — admit, gastro + surgical alert,Day 3 Oxford Index positive — rescue therapy decision same day,Colon >6cm, distension, rising toxicity — emergency surgery,Steroid-refractory — test for CMV colitis on biopsy

Reference: BSG IBD Guidelines 2019 / NICE NG130 Ulcerative Colitis

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