This document provides guidelines for the management of severe ulcerative colitis. It recommends initial treatment with IV methylprednisolone and high dose oral 5-ASA. If the patient does not achieve remission within 3 days, azathioprine or infliximab should be considered. Hospital admission is necessary for IV fluids and antibiotics may be used if there is fever or leukocytosis. Colonoscopy should be avoided due to risk of perforation. Total colectomy is advised if the patient has ≥8 bowel movements or a CRP of ≥45 mg/L.

1. Severe Ulcerative Colitis
United European of Gastroenterology
Ahmed Abdul Ghany

2. Bloody diarrhea ≥ 6 motions/ day
Pulse ≥ 90 bpm
Body temperature ≥ 37.8 C
Hemoglobin ≤ 10.5 g/dl
ESR ≥ 30 mm/hr

3. Role of Colonoscopy
Full colonoscopy should NOT be made due to
risk of perforation instead flexible endoscopy
may be indicated to assess severity.

4. Management
• Hospital admission for IV fluids and electrolyte
replacement.
• DVT and pulmonary embolism prophylaxis
• IV antibiotics ONLY in patients with high grade
fever, leukocytosis and megacolon.
• Enteral nutrition is preferred (NPO in
fulminant colitis)

5. Initial therapy
• Methylprednisolone 20 mg IV every 8 hrs for 1
week.
• High dose oral 5-ASA (Pentaza 4.8 gm daily)
• 5-ASA / steroids enemas and suppository

6. Maintenance therapy
• Patients who respond to IV glucocorticoids
should be converted to equivalent dose of oral
steroids
• Oral steroids tapered after 2- 4 weeks
• Rectal 5- ASA / Steroids can be tapered over 2
– 4 months
• Oral 5- ASA should be continued at the same
dose.

7. If he patient did not achieve remission (≤ 3
motions a day) by day 3 consider using second
line therapy: Azathioprine or Infliximab.

8. COLECTOMY
• For patients having 4- 8 motions with blood
and CRP ≥ 45 mg/L or motions ≥ 8 without
blood, the likelihood for later colectomy
during the same admission was 85%.
• Total colectomy with ileostomy with
preservation of the rectum is advised for a
later restorative procedure.

9. SURVEILLANCE