Treatment of Acute Severe Ulcerative Colitis

Medically Reviewed by Minesh Khatri, MD on June 05, 2022
4 min read

For the 907,000 Americans with ulcerative colitis, living with symptoms like urgent bowel movements, abdominal cramps, and loose or bloody stools can be overwhelming, but treatments can help keep symptoms in check.

Ulcerative colitis is a chronic disease, and most people have mild to moderate symptoms (called flares) that alternate with periods of remission. Between 10% and 20% of people with ulcerative colitis will have a more aggressive form of the disease called acute severe ulcerative colitis.

Acute severe ulcerative colitis (ASUC) is a serious complication of ulcerative colitis. It’s diagnosed when the disease flares and causes frequent bowel movements and bloody diarrhea, rapid heart rate, abdominal tenderness, fever, high levels of inflammation, and anemia. Inflammation in the intestinal wall makes the colon swollen and dilated, causing the stomach to become bloated. This is linked to a risk of developing toxic megacolon, the most serious complication of colitis.

ASUC is considered a medical emergency, and you'll probably be hospitalized to help manage the disease. Without treatment, ASUC could be life-threatening.

ASUC is a challenging condition to treat. Once you're admitted to the emergency room, you'll get a series of tests, including blood tests, stool tests, and an exam of your bowel called a sigmoidoscopy. You'll also get intravenous fluids to boost hydration.

The average hospital stay for ASUC treatment ranges from 4.6 to 12.5 days. During this time, your health care providers may include a gastroenterologist, colorectal surgeon, dietitian, pharmacist, and stomal therapist. The goal of hospitalizing you is to end the flare, get your symptoms under control, and put the disease into remission. Your doctors will want to make sure that rectal bleeding and diarrhea have stopped and normal bowel movements have returned. Rehospitalization is common.

Intravenous steroid medications are the most common treatment for ASUC. For 30% to 40% of ASUC patients, steroid treatments don’t work – and taking steroid medications for more than 10 days increases your risk of complications.

If the steroids don’t help within 3 to 5 days, your health care team will start “medical rescue therapy” with immunosuppressive drugs like cyclosporine or infliximab.

You might get an operation to remove part (or all) of your colon, called a colectomy, if your ASUC doesn’t respond to steroids, immunosuppressants, or other medical treatments.

Research shows that patients who were admitted to the hospital for ASUC with symptoms that included more than eight bowel movements per day and higher levels of inflammation in their blood had an 85% likelihood of needing surgery.

If you have complications like a perforation of the colon or toxic megacolon, surgery will be the first treatment. Delaying surgery could increase your risk of complications following the operation.

Researchers have explored whether medications called Janus kinase (JAK) inhibitors, which block certain enzymes that are overactive in ASUC, could help treat the disease and decrease the number of patients who needed colectomy surgery. The study showed promising results, and research is ongoing.

Most diagnoses of ulcerative colitis are in men between the ages of 15 and 35. The disease course for ASUC can be harder to predict, but it commonly appears between ages 34 and 48.

There is data showing that 54% of those who developed ASUC get it within 1 year of their UC diagnosis; 18% developed ASUC within 1 to 5 years of their initial diagnosis; and 28% were diagnosed with ASUC more than 5 years after their UC diagnosis.

Additional studies show that those who were diagnosed before the age of 40 had an aggressive disease course, had large or deep ulcers on their colons, higher levels of inflammation, were prescribed steroid medications earlier in their disease, and were at a higher risk of severe disease, including ASUC. Men were at higher risk of needing a colectomy than women.

The long-term outlook for ASUC is guarded. There is a 20% chance that you'll need colectomy surgery after your first hospitalization, but that chance rises to 40% after two hospital admissions for ASUC. Severe flares are linked to a 1% risk of death.

Older age is linked with higher death rates. The death rate from ASUC is over 10% in people over 80 compared to fewer than 2% for people between the ages of 50 and 59.

UC is a chronic disease with no cure. Developing acute, severe symptoms is a risk for up to 20% of those diagnosed with the disease. With hospitalization, medical management, and a knowledgeable health care team, you can recover from a bout of ASUC and go into remission, but new flares are possible.