Why is it important?
Acute severe colitis is a potentially life-threatening condition. Approximately 25% of patients with ulcerative colitis will require hospitalisation for an acute severe flare of disease at some stage in the natural history of their disease. Often this will be the first presentation of their disease.1
When a flare occurs in colitis, it can change and deteriorate rapidly. Patients need fast and close monitoring and review by appropriate specialists. There should be clear, evidence-based protocols in place for initial management of inpatients admitted with an IBD flare, which should be carefully followed. Children experiencing an acute episode need immediate access to a paediatric gastroenterologist.
The monitoring stage should include stool cultures to exclude infectious causes, as well as flexible sigmoidoscopy. When it comes to escalating from intravenous steroids to ciclosporin or infliximab rescue therapy or to surgery, it’s important to make decisions quickly to avoid severe complications (intravenous steroids will fail for nearly half of patients). Patients should be kept fully informed of all treatment options throughout, with discussions around potential need for surgery starting early, in order to facilitate quick joint decision-making.
The 2025 BSG Guidelines recommend that patients with acute severe colitis who have not responded within 7 days of rescue therapy with infliximab or ciclosporin, or those with a deterioration or complications before that time (including toxic megacolon, severe haemorrhage or perforation) require subtotal colectomy and ileostomy. Surgical input at an early stage helps patients to understand that colectomy is an important treatment option and is not an outcome to be avoided at any cost. Prompt joint decision-making is essential to avoid unnecessary delays.