Introduction

Acute severe ulcerative colitis (ASUC) is a serious, potentially life-threatening condition. Hospital admission and prompt medical therapy with intravenous steroids is crucial, but rescue medical therapy is frequently needed, and surgery is often required.

Aims & Methods

Our aim was to assess the adherence to main diagnostic and management recommendations within the MASC multinational study. MASC was a prospective, multinational cohort study, including all consecutive patients hospitalized for ASUC between February 2019-January 2020. The primary outcome was surgery during the first 90 days after admission. We used descriptive statistics to determine the proportion of patients fulfilling each diagnostic and treatment recommendation according to ECCO and AGA.

Results

A total of 823 patients from 123 centers in 32 countries in five continents were included (median age 39 years [IQR, 28-54], 56% male, 64% non-smokers; Table 1). Most cases (74%) had a previous diagnosis of ulcerative colitis, and around half (48%) with prior ASUC episodes. Upon admission, they were under 5-ASA therapy (60%), thiopurines (14%), or biologics (21%). They were mostly admitted to the Gastroenterology ward (74%). During the initial assessment, 112 patients (15%) did not have stool culture or C. difficile testing, and CMV was evaluated in 50% of cases. Endoscopic assessment was performed in 66% of patients, mainly by flexible rectosigmoidoscopy (74%).

Regarding treatment, 3.4% of patients received exclusive parenteral nutrition, 70% low molecular weight heparin, and 42% prophylactic antibiotics. Steroids were started after a median of 0 days (IQR, 0-1), mostly with methylprednisolone or hydrocortisone (64%), 26% with other steroids, and 7% were managed without steroids. Infliximab was started in 159 patients (19%) after a median of 6 days (IQR, 4-8) after starting steroids, with 27% after >7 days. Most of the patients (93%) had some type of tuberculosis screening done prior to infliximab. Twenty-eight patients (3.4%) started cyclosporine. Thirty-two patients (4%) received other rescue therapy different from infliximab or cyclosporin. Colectomy was performed in 25 patients (3%).

Conclusion

The diagnostic and medical management of ASUC remains heterogeneous and different from current recommendations. This context demands more evidence and consensus on the best management of ASUC.

Introduction

Rescue treatment is administered to patients with acute severe ulcerative colitis (ASUC) who do not respond sufficiently to the initial treatment with intravenous (iv) corticosteroids. Gastrointestinal ultrasound (GIUS) can be used to detect the degree of inflammation in ulcerative colitis and show response in the treatment of ASUC^1,2, but can it be used to detect treatment response of rescue treatment?

Aims & Methods

Can GIUS be used for early prediction of treatment response in patients receiving rescue treatment for ulcerative colitis?
Patients with ulcerative colitis were included from June 2020 to Nov 2024 at two hospitals in Bergen, Norway and treated with iv corticosteroids. At day 3 to 5 patients with insufficient clinical response were treated with infliximab (10mg/kg) as rescue. The patients were examined with GIUS before rescue treatment (baseline), at the day of the 2nd infusion (after 1-2 weeks) and after 3 months. Bowel wall thickness (BWT), bowel wall vessel density with colour Doppler, loss of haustration and fatty tissue reaction was registered for every segment of the colon as well as an activity score (UC-score) based on these parameters³. The two main outcomes of the study based on the partial MAYO score (pMAYO) at 3 months. Clinical response was defined as a change in pMAYO ≥ 3 points and ≥ 30% and with an absolute reduction in the rectal bleeding score ≥ 1 or with the score for rectal bleeding ≤ 1. Clinical remission was defined as pMAYO ≤2.

Results

68 patients with colitis were recruited and of these 37 failed the initial treatment with iv corticosteroids and were given rescue treatment. At baseline 8 had left-sided colitis while 29 had subtotal or total colitis. After 3 months 3 patients had received surgery, 28/34 had treatment response compared to baseline and 24/34 were in remission. There were significantly more patients with left-sided colitis in remission (p=0.034). At the 2^nd infusion there were no significant differences between responders and non-responders for the GIUS parameters, but patients in remission at 3 months had significantly lower BWT in the ascending colon (1.3 ±0.5 vs 2.9 ±2.2 mm, p=0.002) and the transverse colon (1.7 ±0.9 vs 2.8 ±0.9 mm, p<0.001), lower sum of BWT (9.1 ±3.0 vs 13.1 ±5.0 mm, p=0.005) and UC-score (8.0 ±4.7 vs 12.9 ±7.2, p=0.018). At 3 months there was a significant difference in BWT for all segments, the sum of BWT (7.0 ±2.6 vs 14.0 ±4.5, p<0.001) and the UC-score (3.9 ±4.6 vs 16.3 ±5.6, p<0.001) for responders. For patients in remission similar results were found except for the rectum. The sum of BWT (6.8 ±2.6 vs 11.9 ±4.6 mm, p<0.001) as well as the UC-score (3.8 ±4.6 vs 11.7 ±7.8, p<0.001) was significantly lower.

Conclusion

The significant differences in BWT of the ascending and transverse colon at the 2^nd infusion could reflect prognostic differences between left-sided and total colitis. At 3 months the BWT of all colon segments was lower except for the rectum for patients in remission.

References

1) Ilvemark J, Wilkens R, Thielsen P, et al. Early Intestinal Ultrasound Predicts Intravenous Corticosteroid Response in Hospitalised Patients With Severe Ulcerative Colitis. J Crohns Colitis. Nov 23 2022;16(11):1725-1734. doi:10.1093/ecco-jcc/jjac083
2) Nylund, K., et al. ⟪ Sonorescue⟫-treatment response in acute severe Ulcerative Colitis measured with ultrasound. In: J Crohns Colitis. Great Clarendon St, Oxford OX2 6DP, England: Oxford Univ press, 2025. p. i239-i239.
3) Bots S, Nylund K, Lowenberg M, Gecse K, D'Haens G. Intestinal Ultrasound to Assess Disease Activity in Ulcerative Colitis: Development of a novel UC-Ultrasound Index. J Crohns Colitis. Aug 2 2021;15(8):1264-1271. doi:10.1093/ecco-jcc/jjab002

Disclosure

Odd Helge Gilja has received speaker’s honoraria from AbbVie, Bracco, Allmirall, GE healthcare, Takeda AS, Ferring AS, Allergan and Janssen-Cilag and has served as a consultant for Bracco, GE Healthcare, Takeda and Samsung. ​The other authors have nothing to dislose.

Introduction

Acute Severe Ulcerative Colitis (ASUC) is a serious, potentially life-threatening condition. Hospital admission and prompt medical therapy with intravenous steroids is crucial, but rescue medical therapy with infliximab is frequently needed. Despite its frequency and relevance, there is no clear evidence about the optimal infliximab (IFX) dosing and timing in this context.

Aims & Methods

In a prospective multicentre, international cohort study, consecutive patients hospitalized for ASUC between 2/2019-1/2020 were included. The primary outcome was surgery during the first 90 days after admission (failure of medical treatment). For this analysis we identified and analyzed all patients receiving IFX as rescue therapy during the index admission. We used descriptive statistics along with non-parametric tests to determine patient characteristics and outcomes between IFX usage patterns.

Results

A total of 823 patients from 123 centers in 32 countries in five continents were included (median age 39 years [IQR, 28-54], 56% male, 64% non-smokers). IFX was started in 159 patients (19%) after a median of 6 days (IQR, 4-8) after starting steroids, with 27% after >7 days. The initial IFX dose was mostly 5 mg/kg (74%), followed by 10 mg/kg (23%). The overall response was considered adequate in 74%, this was numerically superior among those receiving 10 mg/kg (83% vs 74%, p=0.5). In 41 patients a second dose of IFX (26%) was administered during the admission. After a first dose of IFX 5 mg/kg or 10 mg/kg, most patients received a subsequent infusion with the same dosing (92% and 79%, respectively). Colectomy was performed in 35 patients (22%), without statistically significant differences between those with an initial dose of 5 or 10 mg/kg (23% vs 19%, p=0.6).

Conclusion

IFX is a relevant rescue therapy, required in around one in five patients with ASUC. Most patients receive 5 mg/kg, and this is usually followed by the same dosage. Still a proportion of patients receive higher doses with 10 mg/kg, but colectomy risk remains similar between both groups.

Introduction

Older adults with ulcerative colitis (UC) have greater morbidity than younger adults, yet there is paucity of data on the management and outcomes of those who present with acute severe ulcerative colitis (ASUC) in this patient population. This study aims to investigate differences in the management and outcomes between older and younger patients hospitalised with ASUC.

Aims & Methods

We conducted a retrospective study on all ASUC presentations to a Quaternary Sydney hospital over a 10-year period. A modified True-love Witts’ Criteria was used to identify ASUC as ≥6 bloody bowel motions daily and presence of at least one systemic feature, including heart rate >90 bpm, temperature >37.8°C, haemoglobin <105 g/L, and C-reactive protein (CRP) ≥30 mg/L. Older patients who presented with ASUC was defined as those ≥65 years old at time of presentation. Data collected on management included rates of rescue therapy, colectomy and TPN requirement. Data collected on outcomes included hospital length of stay and rates of ICU admission, 30- and 90-day readmission, and 30- and 90-day mortality.

Results

A total of 172 presentations met criteria for ASUC. Of these presentations, 148 patients (86.1%) were <65 years old and 24 patients (13.9%) were ≥65 years old. Median age at presentation in older adults was 73.6 years old and in younger adults was 32.0 years old. Older adults had similar rates of need for rescue therapy (37.5% vs 35.1%, p=0.08), colectomy (12.5% vs 9.5%, p=0,64) and TPN (12.5% vs 10.1%, p=0.73), as their younger counterparts. Older adults (n=6, 25.0%) had significantly higher rates of ICU admission (p<0.01) compared to those <65 years old (n=3, 2.0%). Older adults also had significantly higher 30- and 90-day mortality rates (n=3, p<0.01). There was no mortality observed in adults <65 years old. There was no significant difference in 30- and 90-day readmission rates between older adults and those <65 years old at time of ASUC presentation. Table 1 compares management and outcomes in adults <65 years old and ≥65 years old who presented with ASUC.

Table 1. Comparison of management and outcomes in adults <65 years old and ≥65 years old who presented with ASUC

	Age <65 (n=148)	Age ≥ 65 (n=24)	p-value
Received rescue therapy (n, %)	52 (35.1)	9 (37.5)	0.08
Underwent colectomy (n, %)	14 (9.5)	3 (12.5)	0.64
Required TPN (n, %)	15 (10.1)	3 (12.5)	0.73
Required ICU admission (n, %)	3 (2.0)	6 (25.0)	<0.01
30-day readmission (n, %)	22 (14.9)	6 (25.0)	0.21
90-day readmission (n, %)	30 (20.3)	8 (33.3)	0.15
30-day mortality (n, %)	0 (0.0)	3 (12.5)	<0.01
90-day mortality (n, %)	0 (0.0)	3 (12.5)	<0.01
Mean length of stay (days)	10.3	14.0	0.12

Conclusion

Despite similar rates of need for rescue therapy and colectomy, older patients who present with ASUC are more likely to have poorer outcomes, with increased requirement of ICU admission and higher mortality rates compared to patients <65 years old. The higher morbidity and mortality observed in our study in older adults who present with ASUC highlights the need for further research to optimise care pathways and improve outcomes in this patient population.

Introduction

20-25% of ulcerative colitis (UC) patients will experience at least one episode of acute severe colitis (ASUC). Up to 20% of non-responders to medical treatment will require surgery during the index episode. For approximately one third of the patients, ASUC is the first manifestation of the disease, presenting unique challenges.

Aims & Methods

A single-center, retrospective, cohort study. We included adult patients hospitalized in our gastroenterology department with ASUC. We aim to compare the clinical outcomes between patients with new-onset and established UC.

Results

62 (33.5%) patients had new-onset UC, while 123 (66.5%) had established UC. No significant differences were found in demographic and baseline clinical characteristics of the two groups. Patients with new-onset UC experienced longer hospitalizations (19 ± 22 vs. 12 ± 11 days, P = 0.002), longer delay until receiving rescue therapy [11 days (IQR 6) vs. 6 days (IQR 8), (P = 0.014)] and more severe bacterial infections (16% vs. 4%, P = 0.005) compared with patients with established UC. Histological features of chronicity, including architectural distortion, were more frequently observed in patients with established disease. We found no significant differences in steroid response (P = 0.719), need for rescue therapy (P = 0.522), response to rescue therapy (P = 0.234), colectomy (P = 0.655), mortality (P = 0.516) and hospital readmission (P = 0.929) between groups. After one year, colectomy or death occurred in 13.5% of patients. Independent predictors of adverse outcomes included active smoking, extensive colitis, the need for rescue therapy, and severe bacterial infections — but not new-onset disease.

Conclusion

Major clinical outcomes were similar between patients with new onset and established ASUC. These findings support the efficacy of standardized, protocol-driven management in mitigating risks across both groups.

References

Ordás I, Eckmann L, Talamini M, Baumgart DC, Sandborn WJ. Ulcerative colitis. Lancet. 2012;380(9853):1606-1619. doi:10.1016/S0140-6736(12)60150-0
Hindryckx P, Jairath V, D’Haens G. Acute severe ulcerative colitis: from pathophysiology to clinical management. Nat Rev Gastroenterol Hepatol. 2016;13(11):654–664. doi: 10.1038/nrgastro.2016.116
Dhaliwal J, Tertigas D, Carman N, et al. Outcomes Following Acute Severe Colitis at Initial Presentation: A Multi-centre, Prospective, Paediatric Cohort Study. J Crohns Colitis. 2024;18(2):233-245. doi:10.1093/ecco-jcc/jjad143
Spinelli A, Bonovas S, Burisch J, et al. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment. J Crohns Colitis. 2022;16(2):179-189. doi:10.1093/ecco-jcc/jjab177

Introduction

Data on Intestinal Ultrasonography (IUS) in ulcerative colitis (UC) are growing especially in monitoring colonic lesions after therapies. Ultrasonographic parameters derived from studies in Crohn’s disease populations.

Aims & Methods

Aim of our multicenter study was to define IUS parameters of normality and activity in UC patients compared to a healthy control group (HC). Secondary aim was to evaluate severity of colonic lesions using endoscopy as reference standard.
From July 2022 to Oct. 2023, we conducted a multicenter study at 6 IBD centers. Patients (pts) with UC and indication to perform colonoscopy were longitudinally enrolled. HC [no gastrointestinal symptoms, no anemia and normal fecal calprotectin (FC)] were enrolled to establish normal values. The analysis was performed per patient and per segment evaluating colonic wall thickening (CWT), colonic wall flow, Milan Ultrasound Criteria (MUC), Mayo endoscopic score (MES) and partial/full Mayo score. The sample size for UC cohort and HC, the area under (a ROC) curve, Spearman’s correlation among clinical data, FC, IUS and endoscopy were calculated.

Results

180 UC patients and 80 HC were enrolled. In the UC cohort, 53% were male with a median age of 40 years (range 18-78), 64% had extensive colitis and 36% had left colitis. In the HC, 44% were male with a median age of 29 years (range 19-70). Median CWT in comparison to MES in UC patients and median CWT in HC were shown in Table 1. Rectum wall thickening showed higher values than other colonic segments. A CWT> 2.75 mm showed a sensitivity, specificity, NPV and PPV of 54%, 96%, 48% and 97%, respectively, in differentiating UC patients from HC [AUC=0.72]. A rectum wall thickening >4.55 mm showed a sensitivity, specificity, NPV and PPV of 67%, 84%, 56% and 89%, respectively, in differentiating UC patients from HC [AUC=0.82]. A CWT> 3.5 mm showed a sensitivity, specificity, NPV and PPV of 57.4%, 94.3%, 86% and 78%, respectively, in differentiating activity from remission in UC patients [AUC=0.84]. A rectum wall thickening >5 mm showed a sensitivity, specificity, NPV and PPV of 57.5%, 85.7%, 41% and 92%, respectively, in differentiating UC rectal activity from remission [AUC=0.81]. The correlation of the CWT or MUC vs MES was better than clinical data and FC.

Conclusion

		CWT mm median; (range)
		Right colon	Transverse colon	Left colon	Rectum
Healthy control N=80		1.9; (1.2-3.4)	1.8; (1-3.5)	2; (1-3.3)	3.8; (1.5-5.5)§
UC patients	MES 0 N= 36	2.3; (1.1-4)	2.25; (1.4-4.2)°	3; (1.5-4.2)	4; (3-6)*
	MES 1 N=32	1.65; (0.9-3.8)	1.7; (1.2-3.2)°	2.6; (1.5-6)	4.95; (1.9-8)*
	MES 2 N=45	2.1; (1-4)	2.3; (1.3-5.7)°	3.5; (1.3-5.5)	5.15; (3-10)*
	MES 3 N=67	3; (1-7)	3; (1.3-7)°	5.3; (2.7-8.5)	5.5; (3.2-9.7)*
§ Data available in 25 pts *Data available in 108 pts ° Data available in 178 pts

IUS, importantly CWT as the most relevant parameter, is highly accurate to diagnose and detect activity in UC patients.