Acute Severe Colitis Failing First-Line Steroids at 72 Hours
A 28-year-old woman with a 4-year history of pan-ulcerative colitis presents with 9 bloody stools per day, temperature 38.4°C, heart rate 112, hemoglobin 8.9 g/dL, CRP 68 mg/L, and albumin 2.6 g/dL. Flexible sigmoidoscopy shows deep ulcers and loss of vascular pattern to the splenic flexure; biopsies show no CMV inclusions but she is on no antivirals. She has received IV methylprednisolone 60 mg daily for 72 hours with no reduction in stool frequency. Stool testing for C. difficile is negative. She is on prophylactic heparin and has had a CT showing colonic dilation of 6.5 cm without free air. She asks whether she can 'just go home on pills' and whether surgery means a permanent bag.
1. At 72 hours, what defines steroid failure, and what are the next therapeutic steps with their evidence base?
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Steroid failure in acute severe colitis is classically defined by more than 3 stools per day (or persistent bloody stools) plus a CRP above 45 mg/L at day 3 (the Travis criteria); this patient meets that with 9 stools and CRP 68. She also has a colonic diameter of 6.5 cm, which is concerning for impending toxic megacolon and mandates close surgical involvement.
Next steps:
- Rescue medical therapy: infliximab (5 mg/kg) or cyclosporine are the standard rescue agents. Infliximab is generally preferred in this setting; cyclosporine is an alternative, especially if infection concerns dominate. Response is assessed at 24-72 hours after rescue.
- Exclude infection: repeat C. difficile testing and add CMV assessment (serology/PCR or repeat biopsy with immunohistochemistry) since she is steroid-refractory.
- Supportive care: correct electrolytes, transfuse to a reasonable threshold, continue VTE prophylaxis, and involve surgery early.
She should not be discharged on oral steroids; she is failing inpatient therapy.
2. If she does not respond to rescue therapy within 72 hours, what is the surgical approach, and how do you counsel her about stoma permanence?
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Non-response to rescue at 72 hours (or any deterioration, perforation, or worsening dilation) is an indication for surgery - delay increases mortality.
Operation: subtotal colectomy with end ileostomy and rectal stump (Hartmann's-type closure or mucous fistula). This removes the toxic colon, avoids a pelvic dissection in a septic patient, and preserves the rectum for future options. Primary anastomosis is generally avoided in acute severe colitis with sepsis.
Counseling: the ileostomy is usually temporary; after recovery, she may be a candidate for completion proctectomy with IPAA (restorative) or, if the rectum is preserved, a future ileorectal anastomosis in selected cases. Frame it as 'a stoma now, not necessarily forever.' She should understand that delay risks perforation, which carries high mortality, and that surgery is not a failure of medical therapy.
Document that the decision was made with early surgical involvement.