Acute severe ulcerative colitis: timing is everything

The idiopathic inflammatory bowel diseases comprise mainly two types of intestinal disorder, Crohn disease and ulcerative colitis. The clinical course is marked by exacerbations and remissions that occur spontaneously in response to treatment or intercurrent illness. The disease affects approximately 240 000 patients in the UK. Acute severe ulcerative colitis is a medical emergency; prompt effective treatment at the point of admission can avoid significant morbidity and be potentially life-saving. Although such patients need specialist management, it is imperative that emergency care physicians are aware of the important principles of management of this condition to achieve successful outcomes. Corticosteroids remain the cornerstone of initial therapy, but a third of patients will fail to respond, and further management involves critical and timely decisions on whether to use rescue therapy in the form of ciclosporin or infliximab without compromising the health or safety of the patient or to offer timely surgery. The evidence base for the choices for optimal management of this condition is presented.