Acute severe UC in an adult (Truelove and Witts)
6 or more bloody stools/day plus at least 1 of: pulse >90/min, temperature >37.8°C, Hb <105 g/L, ESR >30 mm/h or CRP >30 mg/L.
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Acute Severe Ulcerative Colitis Management (Adult)
Acute Severe Ulcerative Colitis Management (Adult): Acute severe UC in an adult (Truelove and Witts) → Check first: child, pregnancy, surgical emergency...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Warning Check first: child, pregnancy, surgical emergency
Start IV steroids now. Do not wait for stool results.
- Child or adolescent (PUCAI 65 or more): use a paediatric ASUC pathway. Doses here are for adults.
- Pregnant: same steroids, rescue drugs and surgical indications; ganciclovir only after infectious diseases and obstetric advice. Involve obstetric and IBD teams early. Keep radiation low.
- Peritonism, colonic dilatation, massive bleeding or shock: urgent colorectal surgical review now.
03Action Admit: start IV steroids now and test for infection
Joint care by gastroenterology and colorectal surgery from admission.
- Hydrocortisone 100 mg IV 6-hourly or methylprednisolone 60 mg IV daily (adult)
- Stool C. difficile toxin and culture; FBC, CRP, UEC, LFT, albumin, Mg
- Flexible sigmoidoscopy with minimal air within 72 h (ideally 24 h): biopsies for CMV
- Abdominal X-ray for colonic dilatation; CT if perforation is suspected
- LMWH VTE prophylaxis; rectal bleeding is not a reason to withhold it
- Stop opioids, anticholinergics, antidiarrhoeals and NSAIDs; correct K and Mg
- No routine antibiotics; no TPN or bowel rest; encourage enteral nutrition
- Screen now in case rescue therapy is needed: TB (IGRA and chest X-ray), HBV, HCV, HIV, VZV; cholesterol
- Every day: stool chart, vital signs, abdominal examination, CRP
04Warning C. difficile or CMV found: treat it and continue IV steroids
Do not stop steroids because of C. difficile. Get IBD specialist advice before rescue therapy.
- C. difficile: oral vancomycin 125 mg 6-hourly for 10 days (adult), or fidaxomicin 200 mg 12-hourly for 10 days
- Fulminant C. difficile (shock, ileus or megacolon): vancomycin 500 mg orally or by NG tube 6-hourly plus metronidazole 500 mg IV 8-hourly (adult); urgent surgical and infectious diseases review
- CMV colitis on biopsy: ganciclovir 5 mg/kg IV 12-hourly (adult; reduce dose in renal impairment; pregnant: infectious diseases and obstetric advice first); continue steroids or rescue therapy
05Decision Any time: perforation, toxic megacolon, massive bleeding or deterioration?
Reassess every day. Yes: emergency colectomy.
- If Yes
06End Surgical emergency: emergency colectomy with end ileostomy
Resuscitate. Antibiotics for perforation or sepsis. Total (subtotal) abdominal colectomy with end ileostomy; leave the rectum. Do not delay because of recent infliximab or ciclosporin. Continue IV steroid cover through surgery; do not stop steroids abruptly.
If No07Decision Day 3 of IV steroids: >8 stools/day, or 3-8 stools/day with CRP >45 mg/L?
Oxford criteria. Yes predicts colectomy in about 85%.
- If Yes
08Action Steroid-refractory: colorectal surgical review and choose rescue now
Rescue therapy or colectomy. Do not continue IV steroids alone.
- Discuss colectomy and rescue options with the patient
- Before infliximab: TB and HBV results; no active sepsis
- Before ciclosporin: cholesterol, Mg, creatinine, blood pressure
- Past thiopurine failure, low cholesterol or low Mg: infliximab preferred
- Past infliximab failure: discuss ciclosporin with a specialist IBD centre
- Tofacitinib or upadacitinib: not for routine rescue (insufficient data)
- Rescue drug plus prednisolone 20 mg/day or more: offer Pneumocystis prophylaxis, co-trimoxazole 960 mg 3 times a week or 480 mg daily (adult)
09Decision Choose rescue: infliximab, ciclosporin or colectomy
Choose by team experience, previous therapy, albumin and patient choice.
- Infliximab
10Action Rescue option: infliximab 5 mg/kg IV (adult)
Only after TB screen and HBV check. Not with active sepsis, moderate or severe heart failure (NYHA III-IV) or demyelinating disease. Albumin <25 g/L: consider 10 mg/kg first dose (IBD specialist).
- Review every day with the colorectal team
- Not responding 3-5 days after first dose: colorectal review; accelerated dosing only if colectomy is not needed now
- Response: 5 mg/kg at weeks 2 and 6, then infliximab maintenance
- No response within 7 days: colectomy
11End Rescue failed, deterioration or patient choice: subtotal colectomy
End ileostomy; leave the rectum. Do not delay because of recent infliximab or ciclosporin; delayed surgery worsens outcomes. A second rescue drug only at a specialist IBD centre. Continue steroid cover through surgery, then taper; do not stop abruptly.
- Ciclosporin
12Action Rescue option: ciclosporin 2 mg/kg/day IV (adult)
Avoid with low cholesterol or low Mg, renal impairment, uncontrolled hypertension or past thiopurine failure. Use only where the team is experienced with it.
- Trough target 150-250 ng/mL; monitor BP, creatinine, K and Mg
- Serious risks: nephrotoxicity, seizures, severe infection
- Response: oral ciclosporin at twice the IV daily dose in 2 divided doses (trough 100-200 ng/mL), as a bridge to thiopurine
- No response within 7 days: colectomy
- Path rejoins step 11Shared downstream outcome
- Colectomy
- Path rejoins step 11Shared downstream outcome
If No13Action Day 3 criteria not met: continue IV steroids and review every day
Response usually shows by day 3-5. Do not continue IV steroids beyond 7 days without rescue therapy.
14Decision Clear response to IV steroids by day 5-7?
No: treat as steroid-refractory.
- If Yes
15End Clear response: oral prednisolone and a maintenance plan
Prednisolone 40 mg daily, taper over 6-8 weeks (adult). Start maintenance therapy on IBD specialist advice. Early IBD clinic review.
If No- Path rejoins step 08Shared downstream outcome
Guideline Source
ACG Clinical Guideline Update: Ulcerative Colitis in Adults (2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Children and adolescents need a paediatric ASUC pathway (PUCAI, weight-based doses).
- Rescue choice, accelerated infliximab and a second rescue drug need IBD specialist and colorectal surgical input.
- Tofacitinib and upadacitinib are not covered: data in ASUC are insufficient.
- Not yet signed off by a clinical reviewer.
Contraindicated Populations
children and adolescents (use a paediatric ASUC pathway)
Applicable Regions
USAUUKEU
AU: Hb and albumin in g/L. Infliximab (originator and biosimilars) and IV ciclosporin are TGA-registered; PBS authority restrictions apply to infliximab.
EU: ECCO 2022 UC guidelines (medical and surgical treatment).
UK: BSG 2019 IBD guideline (statements 15-20).
US: ACG 2025 UC guideline; ASCRS 2026 UC surgery guideline.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Acute Severe Ulcerative Colitis Management (Adult)?
The Acute Severe Ulcerative Colitis Management (Adult) is a management clinical algorithm for Colorectal Surgery. It provides a structured decision tree to guide clinical decision-making, based on ACG Clinical Guideline Update: Ulcerative Colitis in Adults (2025).
What guideline is the Acute Severe Ulcerative Colitis Management (Adult) based on?
This algorithm is based on ACG Clinical Guideline Update: Ulcerative Colitis in Adults (2025) (DOI: 10.14309/ajg.0000000000003463).
What are the limitations of the Acute Severe Ulcerative Colitis Management (Adult)?
Known limitations include: Adults only. Children and adolescents need a paediatric ASUC pathway (PUCAI, weight-based doses).; Rescue choice, accelerated infliximab and a second rescue drug need IBD specialist and colorectal surgical input.; Tofacitinib and upadacitinib are not covered: data in ASUC are insufficient.; Not yet signed off by a clinical reviewer.. Individual patient factors may require deviation from these recommendations.
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