Severe ulcerative colitis: a personal point of view

In the course of their disease about 15% of all ulcerative colitis patients have a severe attack with evidence of systemic toxicity. On the basis of our personal experience of a recent series of 46 patients, and of a review of the literature, several conclusions can be drawn. A number of more severe attacks (28 out of 46 patients in our series), defined as "fulminating" or "toxic" colitis, must be regarded as major determinants of complications and mortality (4.3% in our series). The disease severity and the presence of signs and symptoms of toxicity seem likely to be determined by the amount of colonic tissue involved by inflammation, both in depth and in extent. A number of laboratory abnormalities are frequently found in the acute phase of severe ulcerative colitis, but C-reactive protein appears the most reliable factor reflecting activity and extension of lesion. Patients with increased small intestinal gas and multiple air-fluid levels, seen on the abdominal plain film, even in the absence of megacolon, must be considered to be gravely ill and at high risk of complications and mortality. With regard to timing of surgery, a short period of medical management (72-120 hrs) is justified to exclude an infectious etiology, to prepare the patient for surgery, and to allow for improvement.