Gastrointestinal and hepatology · Hard
This case is fictional and exists for study. It describes no real patient.
26 years · female
A 26-year-old female presents to the emergency department with a 5-day history of severe bloody diarrhoea, passing stool 8 to 10 times daily, accompanied by tenesmus and severe crampy abdominal pain. She reports feeling lightheaded and severely fatigued. On physical examination, she appears pale and acutely unwell. Her abdomen is mildly distended with generalised tenderness, which is most pronounced in the left lower quadrant, but there is no guarding or rebound tenderness. Bowel sounds are present but sluggish.
Vital signs
- HR
- 112 bpm
- BP
- 100/65 mmHg
- RR
- 22/min
- Temp
- 38.4 °C
- SpO₂
- 98%
Examination findings
- Pale conjunctivae and dry mucous membranes
- Mild abdominal distension with generalised tenderness, non-peritonitic
- Sluggish bowel sounds
Investigations
| Haemoglobin | 8.8 g/dL | reference: 12.0-15.5 |
| White Blood Cells | 16.2 10^9/L | reference: 4.0-11.0 |
| Platelets | 480 10^9/L | reference: 150-400 |
| C-reactive Protein (CRP) | 115 mg/L | reference: 0-5 |
| Serum Albumin | 28 g/L | reference: 35-50 |
| Potassium | 3.3 mmol/L | reference: 3.5-5.0 |
Question 1 of 3
Based on the Truelove and Witts criteria, how should this patient's clinical presentation be classified?
According to Truelove and Witts criteria, Acute Severe Ulcerative Colitis (ASUC) is defined as passing ≥6 bloody stools per day plus at least one feature of systemic toxicity: temperature >37.8 °C, heart rate >90 bpm, haemoglobin <10.5 g/dL, or ESR >30 mm/hr (or significantly elevated CRP). Mild UC involves <4 bloody stools/day without systemic toxicity. Moderate UC falls between mild and severe. Toxic megacolon requires radiographic evidence of colonic dilation (>6 cm) alongside severe systemic toxicity.
Teaching point: Acute Severe Ulcerative Colitis is defined by Truelove and Witts criteria as ≥6 bloody stools/day plus systemic signs (fever, tachycardia, anaemia, or elevated CRP/ESR).
Question 2 of 3
Which initial bedside/radiological investigation should be performed immediately to evaluate for severe acute complications of this condition?
A plain abdominal radiograph (X-ray) is the essential initial radiological investigation to screen for toxic megacolon (transverse colon diameter >6 cm) and bowel perforation (pneumoperitoneum). Full colonoscopy (Option B) is strictly contraindicated in acute severe colitis due to a high risk of bowel perforation; an unprepared flexible sigmoidoscopy with low inflation pressure is preferred if diagnostic confirmation is needed. CT scan (Option D) is not the immediate first-line bedside radiological tool, though used if localized perforation or abscess is suspected. Barium enema (Option C) is contraindicated in acute severe colitis.
Teaching point: A plain abdominal X-ray must be performed urgently in acute severe ulcerative colitis to exclude toxic megacolon and bowel perforation; full colonoscopy is contraindicated.
Question 3 of 3
What is the most appropriate initial medical therapy to induce remission in this patient?
Intravenous corticosteroids (e.g., IV hydrocortisone 100 mg four times daily or IV methylprednisolone) are the standard first-line treatment for acute severe ulcerative colitis. High-dose oral 5-ASAs (Option C) are used for mild-to-moderate UC, not severe disease. IV infliximab (Option A) or ciclosporin are rescue therapies indicated if there is no significant response to IV steroids by day 3 to 5. Subtotal colectomy (Option B) is indicated for patients who fail rescue therapy, or who develop toxic megacolon, perforation, or massive haemorrhage.
Teaching point: First-line medical therapy for Acute Severe Ulcerative Colitis is intravenous corticosteroids; rescue therapy (infliximab or ciclosporin) is considered if no improvement occurs after 3 days.
Key learning points
- Truelove and Witts criteria define Acute Severe Ulcerative Colitis (ASUC) as ≥6 bloody stools/day plus systemic toxicity features (fever, tachycardia, anaemia, elevated ESR/CRP).
- Plain abdominal radiography is mandatory in ASUC to monitor for toxic megacolon (colon diameter >6 cm) and perforation, whereas full colonoscopy is contraindicated.
- First-line pharmacological management for ASUC is intravenous hydrocortisone, with objective assessment on day 3 to determine the need for rescue medical therapy (infliximab/ciclosporin) or colectomy.
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