Inpatient Management of Acute Severe Ulcerative Colitis
Acute severe ulcerative colitis (ASUC) is a potentially life-threatening presentation of ulcerative colitis that in nearly all cases requires inpatient management and coordinated care from hospitalists, gastroenterologists, and surgeons. Even with ideal care, a substantial proportion of patients will ultimately require colectomy, but most patients can avoid surgery with intravenous corticosteroid treatment and if needed, appropriate rescue therapy with infliximab or cyclosporine. In-hospital management requires not only therapies to reduce the inflammation at the heart of the disease process, but also to avoid complications of the disease and its treatment. Care for ASUC must be anticipatory, with patient education and evaluation starting at the time of admission in advance of the possible need for urgent medical or surgical rescue therapy. Here we outline a general approach to the treatment of patients hospitalized with ASUC, highlighting the common pitfalls and critical points in management.
© 2019 Society of Hospital Medicine
Ulcerative colitis (UC) is a chronic inflammatory condition of the colonic mucosa. Classically, it starts in the rectum and can extend continuously from the distal to the proximal colon. The defining clinical symptom of UC is bloody diarrhea, typically accompanied by rectal urgency and mucus discharge. The natural history of this disease includes periods of exacerbations and remissions occurring spontaneously or in response to medical treatment.1
Acute severe ulcerative colitis (ASUC) is a potentially life-threatening complication of UC that typically requires hospitalization and interdisciplinary care between hospitalists, gastroenterologists, and colorectal or general surgeons. The risk of a patient with UC requiring hospitalization for ASUC ranges from 15%-25%2,3 and, in total, UC accounts for 30,000 hospital visits annually.4 The direct medical costs exceed $4 billion annually, with hospital costs of over $960 million.5 Historically, mortality from ASUC was as high as 24% but decreased substantially to 7% after the introduction of systemic corticosteroid therapy.6 Further advances in care have reduced mortality to approximately 1% or less.7,8 Nonetheless, up to 20% of patients admitted with ASUC have a colectomy on their first admission, and this rate rises to 40% after two admissions.2
DEFINING ACUTE SEVERE ULCERATIVE COLITIS
To categorize UC severity, assess patients using the Truelove and Witt’s criteria. The system classifies patients as having mild, moderate, severe, or fulminant disease. Severe disease by these criteria includes patients with >6 bloody bowel movements per day and at least one of the following clinical features: fever (>37.8°C), tachycardia (>90 bpm), anemia (hemoglobin <10.5 g/dl), or elevated inflammatory markers (traditionally, erythrocyte sedimentation rate greater than 30 mm/h or, more recently, C-reactive protein (CRP) greater than 30 mg/L. (Table 1).6,9
Fulminant colitis refers to a subgroup of patients with more than 10 stools per day, continuous bleeding, abdominal pain, colonic dilatation on abdominal X-ray film, and severe toxic symptoms including fever and anorexia. Such patients are at risk of progressing to toxic megacolon and bowel perforation.10
INDICATIONS FOR HOSPITALIZATION AND INPATIENT LEVEL OF CARE
Patients with ASUC almost always require hospitalization for their disease management. In many cases, these patients have been receiving outpatient oral prednisone 40-60 mg daily but continue to have ongoing disease activity.11 Most patients will require close clinical monitoring, frequent blood testing, endoscopic or radiologic evaluation, as well as administration of intravenous corticosteroids. The average length of stay (LOS) ranges from 4.6 to 12.5 days, depending on disease severity.12 Not surprisingly, Kelso et al. reported that predictors of hospital LOS greater than four days include initiating a biologic drug in the hospital, undergoing two or more imaging modalities and treatment with intravenous steroids,13 and so it is rare that patients do not meet billing requirements for an inpatient level of care.
