24th July 2023

Management (ulcerative colitis)

Assessment of severity

Tools used to assess the severity of acute ulcerative colitis include the Truelove and Witts severity index.

Table 3: Truelove and Witts severity index. See References

The severity of disease can also be measured by the extent of the disease, i.e. how far throughout the colon the inflammation has spread.

• Ulcerative proctitis = disease within 18cm of the anal verge and distal to the rectosigmoid junction
• Ulcerative proctosigmoiditis = disease limited to the rectum and sigmoid colon with no involvement of the descending colon
• Left-sided colitis = disease present beyond the sigmoid colon and extending as far as the splenic flexure
• Extensive colitis = continuous inflammation that starts at the rectum and extends beyond the splenic flexure

Mild-moderate disease

Induction of remission 

Topical mesalamine (suppository of enema) is used as the first line for proctitis or proctosigmoiditis, with topical steroids or oral 5-ASA agents as alternatives.

Left-sided or extensive colitis is treated with combination oral and rectal 5-ASA agents. Topical or oral steroids can be added if disease does not initially respond.

Maintenance

For proctitis or proctosigmoiditis, topical mesalamine is also first line, and oral 5-ASA is used if these drugs were required to induce remission.

For left-sided or extensive colitis, topical mesalamine is generally effective for maintenance therapy.

Moderate-severe disease

Induction of remission

Remission can be induced with anti-TNF therapy with or without immunomodulators. Systemic glucocorticoids (intravenous or oral) can be used but should be avoided as part of long-term therapy due to the extensive side effect profile. Failure of a clinical and biochemical response after 3 days of intravenous steroid therapy should prompt an assessment regarding medical rescue therapy or surgical management.

Medical rescue therapy can be administered with either ciclosporin or infliximab. Contraindications to ciclosporin therapy include abnormal renal function, uncontrolled hypertension, uncontrolled infections, malignancy, low serum magnesium, and failure to comply with dosing/monitoring. Contraindications to infliximab include active uncontrolled infection, latent (untreated) TB, demyelinating disease, heart failure, and malignancy.

Maintenance

Maintenance therapy depends on the initial agent required for remission. For example, if an anti-TNF was used to induce remission, then this can be continued. There should be an aim to withdraw immunomodulator therapy based on response to biologic therapy. If glucocorticoids were used for induction, then a thiopurine may be used for maintenance therapy.

Fulminant ulcerative colitis

Typically managed in critical care – treatment is similar to that of acute severe ulcerative colitis, but with more intensive monitoring and the potential for organ support.

Surgical management of ulcerative colitis

May be indicated for patients with acute severe disease, which is refractory to systemic steroids and immunosuppressants. Interventions include total abdominal colectomy with end ileostomy.

Complications such as bowel perforation or toxic megacolon (see below) also necessitate surgical intervention.