On the Bleeding Edge: Mastering GI Emergencies and Inpatient GI Consultation (On-Demand)

Video Transcription

Video Summary

Dr. Rubin reviews practical management of acute severe and fulminant ulcerative colitis, emphasizing early, decisive treatment and avoiding prolonged steroid use. Hospitalized patients should receive prompt surgical consultation, assessment for toxic dilation, VTE prophylaxis, infection testing, and supportive care, including fluids and transfusions when needed. An early, usually unprepped flexible sigmoidoscopy with biopsies helps assess severity and diagnose CMV; confirmed CMV and C. difficile should be treated while colitis therapy continues.<br /><br />IV steroids remain an initial option, but patients who have not substantially improved by day three should move to rescue therapy or surgery rather than continue ineffective steroids. Options include infliximab, cyclosporine, and, increasingly, oral JAK inhibitors. Low albumin and severe inflammation can accelerate infliximab clearance and predict poorer response. JAK inhibitors may act quickly, but inpatient use and dosing remain areas of evolving evidence; steroid exposure should be minimized when combining therapies.<br /><br />Plans for maintenance, medication access, monitoring, and nutrition should be arranged before discharge. Patients should generally be allowed to eat. Surgery should be discussed early and revisited if treatment fails; repeated unsuccessful drug trials can delay necessary surgery and worsen outcomes. The central message is to recognize severity early, involve a multidisciplinary team, and reassess treatment response promptly.

Asset Subtitle

David Rubin, MD, FASGE

Keywords

ulcerative colitis

acute severe colitis

fulminant colitis

IV steroids

rescue therapy

infliximab

cyclosporine

JAK inhibitors

acute severe ulcerative colitis

surgical consultation