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  • Review Article
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Current management of severe ulcerative colitis

Abstract

Approximately 15% of patients with ulcerative colitis develop an acute attack of severe colitis, and 30% of these patients require colectomy. Severe ulcerative colitis is therefore considered a medical emergency, the management of which requires close collaboration between gastroenterologists and surgeons. The mortality rate for patients with severe ulcerative colitis is now <1% in specialist centers, but it was high before intravenous steroid therapy and early surgery were introduced; indeed, mortality is still high in nonspecialized centers. As colectomy severely affects quality of life, therapy with intravenous ciclosporin and, more recently, infliximab has been introduced to try to avoid the need for surgery. Ciclosporin induces short-term remission, but the long-term benefit remains unsatisfactory as colectomy is often only delayed. A significant short-term reduction in the colectomy rate has, however, been observed after infliximab treatment. The use of infliximab versus ciclosporin in patients with severe ulcerative colitis remains to be defined. The timing of surgery remains a cardinal decision in the management of severe ulcerative colitis; increased morbidity resulting from prolonged ineffective medical treatment and, therefore, a delay in surgical treatment should be avoided.

Key Points

  • An acute attack of severe ulcerative colitis must considered a medical emergency

  • The early detection of prognostic factors significantly reduces mortality in patients with severe ulcerative colitis

  • The finding of small-bowel distension on X-ray (so-called impending megacolon) identifies patients at high risk of developing toxic megacolon

  • Ciclosporin or infliximab can be used in patients with severe ulcerative colitis when there is no clear cut clinical response to an intensive treatment regimen with corticosteroids

  • A particularly aggressive therapeutic approach is appropriate in patients with symptoms of multiple organ dysfunction

  • The timing of colectomy remains the most important decision to be made by the gastroenterologist in conjunction with the surgeon

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Figure 1: Plain abdominal X-ray films of a patient with severe colitis.
Figure 2: Clinical algorithm for the management of uncomplicated severe ulcerative colitis adopted at the GI Unit, University of Rome “La Sapienza”.
Figure 3: Clinical algorithm for the management of toxic megacolon adopted at the GI Unit, University of Rome “La Sapienza”.

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Correspondence to Renzo Caprilli.

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Caprilli, R., Viscido, A. & Latella, G. Current management of severe ulcerative colitis. Nat Rev Gastroenterol Hepatol 4, 92–101 (2007). https://doi.org/10.1038/ncpgasthep0687

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