Management of acute, severe ulcerative colitis

When a patient is hospitalized with acute, severe ulcerative colitis, the primary decision is whether or not to proceed directly to surgery. Absolute indications for an immediate colectomy include exsanguinating hemorrhage, perforation and cancer. If medical therapy is undertaken, however, the decision for urgent surgery or non-operative salvage therapy will still be required in 15-50% of the patients in which there is a failure to respond within 3-5 days to a standard regimen of i.v. steroids, antibiotics, decompressive maneuvers, fluid and electrolyte replacement and other supportive measures. The options for medical salvage therapy are usually cyclosporine or infliximab. There are theoretical and practical arguments on each side; the current GETAID and CONSTRUCT trials will probably provide support for either. The choice between colectomy or medical salvage therapy, however, must not be delayed under any circumstances. Before choosing salvage therapy, one must first be certain that there is the luxury of time, that there is a post-hospital strategy for the maintenance of remission and that the colon is worth saving. The priority is not so much saving colons as it is saving lives.