• Acute severe colitis
• clinical decision-making
• colectomy
• IBD clinical
• IBD surgery
• management
• prediction
• ulcerative colitis

Acute severe ulcerative colitis is a potentially life-threatening condition. It is most readily identified by the criteria of Truelove and Witts,1 which have been adopted by international bodies: a patient who has a bloody stool frequency of six or more per day and tachycardia (>90 bpm, or temperature greater than 37.8°C, or anaemia (haemoglobin <10.5 g/dl), or an elevated erythrocyte sedimentation rate (ESR) (>30 mm/h).1–4 However, the response to intensive treatment with corticosteroids has remained unchanged for 50 years. In a systematic review of 32 trials of steroid therapy for acute severe colitis involving 1991 patients from 1974 to 2006, the overall response to intravenous hydrocortisone, methylprednisolone, or betamethasone was 67% (95% CI 65% to 69%), and 29% (95% CI 28% to 31%) came to colectomy.5 The only major difference from 1955 was that mortality was 1% (95% CI 0.7% to 1.6%) and not 7%. The colectomy rate did not change between 1974 and 2006.

The UK national inflammatory bowel disease audit in 2008 identified a mortality of 2.8% among 317 patients.6 Old age dominated death (11/16 who died were aged 80–89years), but the morbidity in young people has yet to be quantified. A nationwide linkage analysis in Scotland also strongly implicates age as the critical determinant of mortality in patients hospitalised for ulcerative colitis—the 3-year mortality in 245 patients aged 65 years and over was 39%, whereas none of 212 patients aged 30 years or less died (p<0.001).7 Co-morbidity was independently associated with mortality, but it remains unclear whether older people die from co-morbidity, complications of immunosuppression, delayed surgery, or surgery itself. The prime concern in managing acute severe colitis must be to reduce both morbidity and mortality.

We address two principal clinical dilemmas in managing acute severe colitis: how to identify at an early stage those who are likely …