Identification and surgical management of acute severe ulcerative colitis: A guide for general practitioners

Abstract

IN 2021, ulcerative colitis (UC) patients were estimated to account for 334 out of every 100,000 patients presenting to general practitioners (GPs) in Australia. 1 A severe complication, known as acute severe UC (ASUC), is seen in up to 25% of this population and requires swift and decisive emergency care to prevent further deterioration. 2 Recognising the clinical significance and the potential effects of ASUC on patient outcomes, the goal of this article is two-fold. First, it aims to equip both rural-and urban-based GPs to swiftly identify patients with ASUC. Second, this article underscores the importance of holistic patient management. This includes insights into in-hospital care regimens tailored for ASUC patients and postoperative considerations that can influence patient recovery and long-term outcomes. Clinical features and risk stratificationFrom a surgical perspective, the Truelove and Witts severity criteria is the most sensitive and prevalently used for defining ASUC. 3,4 A patient with ASUC typically exhibits at least six bloody motions daily and a minimum of one sign of systemic toxicity, as detailed in Table 1. 4 Australian guidelines, based on the Montreal classification, stratify risk into mild (≤4 stools without blood), moderate (>4 with or without blood) and severe (≥6 stools, with blood and signs of toxicity). 5 However, assessment tools such as the Mayo clinic score 6 and the Montreal classification 7 have limited use in a surgical setting due to a paucity of validation data. 3,8 Regardless of the chosen criteria, the classification of severity requires periodic re-evaluation. Evaluation by the treating teamThe treating team's assessment usually involves pre-treatment evaluation with biochemical and microbiological studies, diagnostic imaging, and endoscopic investigations to further define the severity and extent of the inflammation. The GP might wish to initiate investigations, where practical, particularly when specialist care is not readily available.