Treatment of Severe Ulcerative Colitis

Severe ulcerative colitis (UC) was first defined by Truelove and Witts in 1955 using six simple criteria without any requirement for a sigmoidoscopic examination—six or more stools per day with one of the following: large amounts of blood, fever >37.8 °C, tachycardia >90, ESR > 30 mm/h, and hemoglobin <10.5 g/dl. These criteria are easily measured and have stood the test of time over half a century. The Mayo Clinic Index (with slight variations also known as the Sutherland Index or the UC Disease Activity Index) has become a frequently used scoring index in clinical trials and includes sigmoidoscopic appearance and the physician’s global assessment. Another score known as the Modified Truelove-Witts Scoring Index, or the Lichtiger score, has been used most frequently in patients with intravenous (IV) corticosteroid-refractory UC. The Lichtiger score includes assessments for nocturnal bowel movements, incontinence, abdominal pain, cramping and tenderness, and the overall sense of “well-being.” While all of these scores list the salient features defining disease activity, the term “severe ulcerative colitis” as used in this chapter will refer to those patients with ongoing frequent bloody diarrhea with systemic signs and/or symptoms that significantly limit the patient’s quality of life and who fail to improve with maximal outpatient therapies and require hospitalization for further management.