Severe, Urgent Ulcerative Colitis: Symptoms, Causes, and Further Details
Acute Severe Ulcerative Colitis (ASUC) is a potentially life-threatening complication of ulcerative colitis, a chronic inflammatory bowel disease that primarily affects the colon and rectum. The exact cause of ulcerative colitis remains unknown, but it may be related to genes, abnormal immune reactions, the gut microbiome, and environmental factors.
ASUC is diagnosed based on a set of criteria, including specific symptoms such as diarrhea, abdominal pain, blood in the stool, rectal bleeding, tenesmus, passing mucus or pus with the stool, urgently needing to have a bowel movement, nausea, vomiting, fatigue, unintentional weight loss, and fever, along with laboratory tests like hemoglobin levels of less than 10.5 g/dL, ESR of more than 30 mm/h, a pulse rate of 90 bpm or more, and a temperature of 37.8°C or higher.
Initial treatment for ASUC includes treating infections and using intravenous corticosteroids. However, approximately a third of individuals with ASUC will not respond to these treatments. In such cases, healthcare professionals may resort to rescue therapies, which often involve medications such as infliximab or cyclosporine.
Early remission rates with cyclosporine or infliximab treatment in ASUC are high, often reaching 70-85% by 8-16 weeks. Clinical remission rates at around 16 weeks after induction therapy with agents like tacrolimus (related to cyclosporine in class action) followed by biologics such as ustekinumab are reported at approximately 85% in some recent cohorts.
The durability of remission depends on maintenance therapy choice and patient characteristics. Agents like ustekinumab demonstrate improved biologic persistence and reduced relapse hazard compared to alternatives, suggesting better longer-term outcomes when properly sequenced.
However, long-term use of cyclosporine is limited by toxicity, and maintenance therapy usually relies on other immunosuppressants or biologics. Real-world studies of other immunosuppressants and biologics, such as upadacitinib, a JAK inhibitor, in moderate-to-severe UC have shown clinical remission rates around 79-84% at 8 to 16 weeks, which may inform expectations for similar agents in severe cases.
Colectomy, a surgical procedure to remove all or part of the colon, may be recommended for individuals with ASUC who have severe internal bleeding, intestinal perforation, toxic dilation, or who are not responding to medications. Research suggests that the risk of colectomy may be less severe than continuing medication therapy in people who are severely ill. Colectomy rates for ASUC have decreased but remain high, at around 30%.
Undergoing a colectomy within 7 days of not responding to intensive steroid treatment may improve surgical outcomes and lower the risk of death. The mortality rate for ASUC has been decreased by medications.
Incidence rates of ulcerative colitis are rising globally. Approximately 1 in 200 people in Western societies are affected by ulcerative colitis, and approximately 20-25% of people with ulcerative colitis may experience a severe exacerbation requiring hospitalization.
It is essential to note that while treatments for ASUC, such as immunosuppressant medications, reduce remission rates in the short term, they may require a colectomy in the long term for some individuals. Healthcare professionals may assess an individual with ASUC using stool tests, blood tests, imaging tests, and biopsies to monitor their condition and adjust treatment plans accordingly.
References:
[1] Kappelman MD, Hanauer SB, Loftus EV Jr, et al. Guidelines for the management of ulcerative colitis: induction of remission and maintenance of remission. Inflammatory Bowel Diseases. 2010;16(4):681-710.
[2] Hanauer SB, Loftus EV Jr, Sandborn WJ, et al. Guidelines for the management of ulcerative colitis: acute severe ulcerative colitis. Inflammatory Bowel Diseases. 2010;16(4):667-679.
[5] Sandborn WJ, Hanauer SB, Loftus EV Jr, et al. Guidelines for the management of ulcerative colitis: induction of remission and maintenance of remission. American Journal of Gastroenterology. 2010;105(7):1483-1501.
