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Severe ulcerative colitis — ABIM Board MCQ

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ModerateGastroenterology/HepatologySevere ulcerative colitisABIM Board

A 34-year-old woman with ulcerative colitis is admitted with 9 bloody bowel movements daily, a temperature of 38.2°C (100.8°F), a pulse of 112/min, and a C-reactive protein level of 88 mg/L. She has no peritoneal signs. Abdominal radiography shows no colonic dilation, and stool testing for Clostridioides difficile is negative. She has not yet received systemic corticosteroids for this flare. Which of the following is the most appropriate initial pharmacologic treatment?

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Correct answer: A — Intravenous methylprednisolone

This patient has acute severe ulcerative colitis, demonstrated by more than 6 bloody stools daily plus systemic toxicity, including fever, tachycardia, and markedly elevated CRP. Initial treatment is hospitalization and intravenous corticosteroids, such as methylprednisolone 40–60 mg daily, with assessment for response after approximately 3 days. Mesalamine alone is inadequate for acute severe disease. Loperamide should be avoided because reduced colonic motility may precipitate toxic megacolon. Azathioprine has a slow onset and is not suitable for induction of remission. Routine antibiotics do not improve uncomplicated acute severe ulcerative colitis and are reserved for suspected infection, perforation, or other septic complications. Steroid nonresponse would prompt rescue therapy with infliximab or cyclosporine and early surgical consultation.

Reference: Samaan MA, et al. Recommendations on the Appropriate Management of Steroids and Discharge Planning During and After Hospital Admission for Moderate-Severe Ulcerative Colitis: Results of a RAND Appropriateness Panel. 2022. https://pubmed.ncbi.nlm.nih.gov/35416799/