skip to main content

Acute severe ulcerative colitis — ABIM Board MCQ

Instant feedback + full explanation. One question, done properly.

HardGastroenterology/HepatologyAcute severe ulcerative colitisABIM Board

A 32-year-old woman with ulcerative colitis is hospitalized on the first day of a flare with 10 bloody stools daily, temperature 38.3°C (100.9°F), and pulse 112/min. Hemoglobin is 9.8 g/dL, albumin is 2.6 g/dL, and C-reactive protein is 78 mg/L. Abdominal radiography shows no colonic dilation or free air. Stool testing for Clostridioides difficile and enteric pathogens is negative. Flexible sigmoidoscopy shows severe continuous colitis; biopsy specimens show no cytomegalovirus inclusions. She has no peritoneal signs or uncontrolled hemorrhage and has not yet received systemic corticosteroids during this flare. Which disease-directed treatment should be initiated now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Intravenous methylprednisolone 40–60 mg daily

This patient meets criteria for acute severe ulcerative colitis: at least 6 bloody stools daily plus systemic toxicity, anemia, and markedly elevated inflammatory markers. After infection and immediate surgical complications have been excluded, initial disease-directed treatment is intravenous methylprednisolone 40–60 mg/day. Her hypoalbuminemia and high CRP predict an increased risk of corticosteroid failure but do not justify bypassing the standard initial corticosteroid trial. Response should be formally reassessed after approximately 3 days. Infliximab or intravenous cyclosporine is rescue therapy for inadequate corticosteroid response, rather than routine initial monotherapy. Upadacitinib is not established guideline-standard first-line monotherapy for hospitalized acute severe disease. Urgent subtotal colectomy is indicated for perforation, toxic megacolon, uncontrolled hemorrhage, clinical deterioration, or failure of appropriately timed medical and rescue therapy.

Reference: American Gastroenterological Association Institute, Clinical Guideline on the Management of Moderate to Severe Ulcerative Colitis, section “Management of Hospitalized Patients With Acute Severe Ulcerative Colitis,” 2020. https://pmc.ncbi.nlm.nih.gov/articles/PMC7175923/