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Journal of Crohn's and Colitis: 9 (4)


Laurence J. Egan, Ireland

Associate Editors

Maria T. Abreu, USAShomron Ben-Horin, IsraelSilvio Danese, ItalyPeter Lakatos, HungaryMiles Parkes, UKGijs van den Brink, NLSéverine Vermeire, Belgium


Published on behalf of

Second European evidence-based consensus on the diagnosis and management of ulcerative colitis Part 2: Current management

Axel Dignass , James O. Lindsay , Andreas Sturm , Alastair Windsor , Jean-Frederic Colombel , Mathieu Allez , Gert D'Haens , André D'Hoore , Gerassimos Mantzaris , Gottfried Novacek , Tom Öresland , Walter Reinisch , Miquel Sans , Eduard Stange , Severine Vermeire , Simon Travis , Gert Van Assche
DOI: http://dx.doi.org/10.1016/j.crohns.2012.09.002 991-1030 First published online: 1 December 2012
  • Ulcerative colitis
  • Surgery
  • Ileo-anal pouch anastamosis
  • Treatment
  • Immunosuppressant

5 Medical management of active ulcerative colitis

5.1 General

When deciding the appropriate treatment strategy for active ulcerative colitis one should consider the activity, distribution (proctitis, left-sided, extensive1), and pattern of disease. The disease pattern includes relapse frequency, course of disease, response to previous medications, side-effect profile of medication and extra-intestinal manifestations. The age at onset and disease duration may also be important factors.

5.1.1 Disease activity

The principal disease activity scoring systems used in clinical trials are covered in Section 1.2 and have been comprehensively reviewed.2 However there are some practical points that are relevant for routine clinical use. For example, it is most important to distinguish patients with severe ulcerative colitis necessitating hospital admission from those with mild or moderately active disease who can generally be managed as outpatients. The simplest, best validated and most widely used index for identifying severe UC remains that of Truelove and Witts3: any patient who has a bloody stool frequency ≥ 6/day and a tachycardia (> 90 bpm), or temperature > 37.8 °C, or anaemia (haemoglobin < 10.5 g/dL), or an elevated ESR (> 30 mm/h) has severe ulcerative colitis (Table 1.3). Only one additional criterion in addition to the bloody stool frequency ≥ 6/day is needed to define a severe attack.4,5

It should be standard practice to confirm the presence of active colitis by sigmoidoscopy before starting treatment. Flexible sigmoidoscopy and biopsy may exclude unexpected causes of symptoms that mimic active disease such as cytomegalovirus colitis, rectal mucosal prolapse, Crohn's disease, malignancy, or even irritable bowel syndrome and haemorrhoidal bleeding. There may be a significant overlap between other diseases that mimic ulcerative colitis and the broad spectrum of UC damage.6,7 In addition, all patients with active disease require stool cultures with Clostridium difficile toxin assay to exclude enteric infection. Patients with an appropriate …

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