Ulcerative colitis (UC) is a chronic inflammatory bowel disease of the large intestine, with symptoms ranging from mild to severe. The disease course involves periods of remission, where symptoms are minimal, alternating with flare-ups of varying intensity. This article focuses on severe ulcerative colitis, exploring its diagnosis, management, treatments, and potential health risks.
Defining Severe Ulcerative Colitis
The distinction between mild, moderate, and severe ulcerative colitis is based on a clinical assessment. A framework known as the Truelove and Witts’ criteria helps classify a flare-up’s severity.
To be diagnosed with severe UC, a person must have six or more bloody stools per day. This symptom must also be accompanied by at least one sign of a systemic inflammatory response.
These systemic signs include a fever above 37.8°C, a heart rate over 90 beats per minute, or anemia with hemoglobin levels below 10.5 g/dL. Another indicator is an erythrocyte sedimentation rate (ESR), a blood test measuring inflammation, higher than 30 mm/hour.
Hospitalization and Acute Management
Acute severe ulcerative colitis is a medical emergency requiring hospitalization to stabilize the patient and control inflammation. Initial management focuses on supportive care and anti-inflammatory treatment.
Patients receive intravenous (IV) fluids to correct dehydration and electrolyte imbalances from diarrhea. Nutritional support is also provided to address malnutrition from the disease’s impact on appetite and nutrient absorption.
The primary treatment is high-dose IV corticosteroids, such as methylprednisolone or hydrocortisone, to rapidly suppress the immune system. The goal is to control the flare-up and reduce symptoms, and the clinical response is closely monitored.
Advanced Medical Therapies
When a patient’s condition does not improve with IV steroids, a state known as steroid-refractory UC, doctors move to advanced therapies. These treatments, also used for long-term management, are categorized into biologics and small molecule drugs that target the immune system.
Biologic drugs are proteins designed to block specific inflammatory pathways. One class, anti-TNF agents like infliximab, targets a protein that promotes inflammation in the gut. Another biologic, vedolizumab, is an anti-integrin therapy that prevents inflammatory cells from entering colon tissue. These medications are administered by intravenous infusion or injection.
A different class, small molecule drugs, includes Janus kinase (JAK) inhibitors like tofacitinib. These oral drugs work inside cells to block inflammatory signaling pathways. They offer a rapidly acting alternative for patients who have not responded to other treatments, including biologics.
Surgical Intervention
For severe UC that does not respond to medical therapy, or in an emergency like a bowel perforation, surgery becomes a treatment option. The standard procedure is a proctocolectomy, which is the complete removal of the colon and rectum. There are two primary surgical outcomes after this procedure.
The most common restorative option is the ileal pouch-anal anastomosis (IPAA), or J-pouch. The surgeon constructs an internal pouch from the end of the small intestine and connects it to the anus, allowing for the eventual passage of stool naturally. This is often performed in stages and may require a temporary ileostomy to allow the pouch to heal.
The alternative is a permanent end ileostomy. This procedure involves creating a stoma, an opening on the abdomen where the end of the small intestine is brought to the surface. A person with an ileostomy wears an external pouch over the stoma to collect waste.
Potential Complications
Severe, uncontrolled inflammation from ulcerative colitis can lead to serious complications. One of the most urgent risks is toxic megacolon, a condition where inflammation causes the colon to rapidly dilate and swell. This can prevent the movement of gas and feces, leading to a risk of rupture, or perforation, of the colon wall. A perforated colon can spill its contents into the abdominal cavity, causing a severe infection known as peritonitis.
Beyond these acute emergencies, long-standing ulcerative colitis increases the risk of developing colon cancer. The chronic inflammation can cause changes in the cells lining the colon, which may become cancerous. The risk is higher for individuals who have had UC for many years and whose disease affects a large portion of the colon.
Because of this, regular surveillance colonoscopies are recommended to detect and remove any precancerous changes.