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Zorluk: ZorGastroenterology and Hepatology

A 2828-year-old woman with a history of ulcerative colitis presents to the emergency department with a 44-day history of 88 to 1010 bloody bowel movements daily, severe abdominal cramps, and subjective fever. Her temperature is 38.4∘C38.4^\circ\text{C} (101.1∘F101.1^\circ\text{F}), pulse is 112/min112/\text{min}, and blood pressure is 105/65 mm Hg105/65\text{ mm Hg}. Physical examination reveals diffuse lower abdominal tenderness without rebound or guarding. Laboratory studies show a hemoglobin of 9.8 g/dL9.8\text{ g/dL}, leukocyte count of 14,500/mm314,500/\text{mm}^3, and C-reactive protein of 65 mg/L65\text{ mg/L}. She meets the Truelove and Witts criteria for acute severe ulcerative colitis. Arrange the following diagnostic and therapeutic steps in the optimal chronological sequence for the management of this patient.

  1. 1Obtain an abdominal radiograph and stool assays for Clostridioides difficile.
  2. 2Initiate high-dose intravenous corticosteroid therapy.
  3. 3Assess for objective clinical response at 72 hours.
  4. 4Administer medical rescue therapy with infliximab or cyclosporine.
  5. 5Proceed with urgent total abdominal colectomy with end ileostomy.

Cevap

The correct sequence is: 1) Obtain an abdominal radiograph and stool assays, 2) Initiate high-dose intravenous corticosteroid therapy, 3) Assess for objective clinical response at 72 hours, 4) Administer medical rescue therapy, 5) Proceed with urgent total abdominal colectomy.
The management of acute severe ulcerative colitis follows a strict, step-wise algorithm designed to induce rapid remission while minimizing the risk of life-threatening complications. Initial steps must prioritize ruling out contraindications to immunosuppression (e.g., infection, megacolon), followed immediately by the first-line standard of care (intravenous corticosteroids). Because a significant proportion of patients are steroid-refractory, a scheduled reassessment at 72 hours is mandatory. Failure at this juncture dictates the use of biologic or immunomodulator rescue therapies, with surgery reserved as the final definitive option for medical failure.

Adım Adım Çözüm

1
Exclude infectious triggers and anatomical complications.
An abdominal radiograph rules out toxic megacolon, and stool assays evaluate for superimposed Clostridioides difficile infection.
Administering high-dose immunosuppression in the presence of megacolon or active C. difficile can lead to fatal bowel perforation.
2
Begin primary induction therapy.
Intravenous methylprednisolone or hydrocortisone is administered.
Intravenous corticosteroids are the cornerstone of treatment for acute severe ulcerative colitis (ASUC) without immediate surgical indications.
3
Evaluate steroid responsiveness.
Clinical status, including stool frequency and C-reactive protein levels, is formally assessed at hospital day 3.
Approximately 30-40% of patients are steroid-refractory; early and objective identification allows prompt escalation of therapy.
4
Initiate second-line medical induction.
Infliximab or cyclosporine is given as rescue therapy.
Medical rescue therapy is necessary for patients failing intravenous steroids to prevent the need for immediate colectomy.
5
Perform surgical management.
Total abdominal colectomy is performed.
Surgery is the definitive treatment if all medical rescue therapies fail or if acute surgical indications (e.g., toxic megacolon, perforation) arise at any point during hospitalization.

Anahtar Kavram

The step-wise management of acute severe ulcerative colitis involves ruling out contraindications, initiating intravenous steroids, assessing response at 72 hours, escalating to rescue biologics if refractory, and reserving colectomy for medical failure.
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Gastroenterology and Hepatology

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