Review article: medical treatment of severe ulcerative colitis M. DAPERNO, R. SOSTEGNI, R. ROCCA, C. RIGAZIO, N. SCAGLIONE, F. CASTELLINO, E. ERCOLE & A. PERA U.O.A. Di Gastroenterologia, Ospedale Mauriziano Umberto I, Torino, Italy SUMMARY Approximately 15% of patients with ulcerative colitis have a severe attack requiring hospitalization at some time during their illness. This treatment leads to a remission in 60–80% of patients and non-responders may require a total colectomy. Mortality in severe episodes of ulcerative colitis decreased from 31–61% in the 1950s to 5–9% in the 1960s thanks to the introduction of steroids and to a policy of early colec- tomy. Recently, some new drugs have been shown to be effective in the treatment of severe steroid-refractory ulcerative colitis. This review concentrates on the clinical evaluation, prognostic factors and new developments in medical therapy in severe ulcerative colitis. A retrospec- tive evaluation of a consecutive series of patients with severe ulcerative colitis admitted to a Gastroenterology Department in Torino, Italy, is also reported. INTRODUCTION Approximately 15% of patients with ulcerative colitis have a severe attack requiring hospitalization at some time during their illness. Treatment with intravenous corticosteroids and a policy of early colectomy originally reduced the mortality in severe episodes of ulcerative colitis from 31–61% in the 1950s to 5–9% in 1960s. In referral centres or in gastroenterological departments with an interest in colitis, mortality is now 3% or less, including operative mortality, if a careful and frequent monitoring is provided by a dedicated gastroenterolog- ical–surgical team. 1 DIAGNOSIS Patients with severe ulcerative colitis usually present with bloody diarrhoea. Urgency, tenesmus, fever and abdominal pain may also occur. At presentation it is important to differentiate ulcerative colitis or Crohn’s colitis from infectious or ischaemic colitis, post-radiation colitis and from rarer forms such as vasculitis or drug-induced colitides. A prompt proctosigmoidoscopy with biopsy for Cyto- megalovirus (without bowel preparation and without air insufflation) and faecal examination (including culture, search for ova, parasites and test for Clostridium difficile toxin) must be done in order to rule out infectious colitis. Generally, medical history, faecal culture and endoscopic appearance are sufficient to make a preliminary diagnosis of ulcerative colitis. DEFINITION OF SEVERITY The next step is to evaluate the severity of the attack and the presence of factors predictive of the efficacy of treatment in order to start a therapy as quickly as possible and to prevent complications. The most com- monly used criteria for evaluation of activity are those proposed by Truelove & Witts in 1955, 2 summarized in Table 1. Later, the Oxford group modified the original criteria and proposed to define a severe attack of ulcerative colitis if a patient had six bloody bowel movements per day, plus one or more of the other variables. 3 It is generally accepted that the number of daily bloody stools is the most important independent clinical variable in the assessment of severity. 4, 5 In clinical trials a Clinical Activity Index 6 has been proposed (Table 2), because it gives a numerical value which can be followed over time. Ó 2002 Blackwell Science Ltd 7 Correspondence to: Dr A. Pera, U.O.A. Di Gastroenterologia, Ospedale Mauriziano Umberto I, Largo Turati 62, 10128 Torino, Italy. E-mail: apera@mauriziano.it Aliment Pharmacol Ther 2002; 16 (Suppl. 4): 7–12.