Treatment of acute severe ulcerative colitis

Abstract

Acute severe exacerbations of ulcerative colitis (ASC) are relatively rare but serious events in children. ASC can occur in patients with new onset or established disease. Children with ASC should be hospitalized and reevaluated frequently to assess for response to treatment and for potential complications. Contributing infections should be ruled out. Currently, intravenous corticosteroids remain the first-line treatment for most children with ASC. Response to corticosteroids should be monitored closely, and the Pediatric Ulcerative Colitis Activity Index (PUCAI) should be measured daily. A PUCAI score >45 on day 3 should prompt discussion and planning for second-line rescue therapy. A PUCAI score >65 on day 5 should prompt initiation of second-line therapy. Infliximab and calcineurin inhibitors effectively reduce the need for colectomy before discharge. Infliximab can be used to maintain and prolong remission, while calcineurin inhibitors are generally used for 3-6 months as a bridge to another maintenance therapy. Sequential rescue therapy is not currently recommended. Surgical indications in ASC include perforation, toxic megacolon, massive hemorrhage, or failure to respond to maximal medical management. If needed, restorative proctocolectomy is the surgery of choice.