A 30-year-old man presents with bloody diarrhoea, abdominal cramps, and fever. Colonoscopy shows continuous mucosal inflammation from rectum to splenic flexure with pseudopolyps. Biopsy shows cryptitis and crypt abscesses without granulomas. He has severe UC (Truelove-Witts criteria). IV hydrocortisone is started. After 3 days there is no improvement. What is the next step?

• A Increase hydrocortisone dose to 500 mg/day
• B Infliximab (rescue therapy) or cyclosporine, and surgical consultation ✓
• C Add oral mesalazine to IV steroids
• D Perform colonoscopy-guided steroid injection

Explanation

In acute severe ulcerative colitis (ASUC) failing IV steroids at 3 days (Day 3 criteria: stool frequency >8/day or 3–8 stools/day with CRP >45 mg/L — Oxford criteria), rescue therapy with infliximab (5 mg/kg IV) or cyclosporine (2 mg/kg IV) is recommended alongside urgent surgical consultation for colectomy if rescue therapy fails. The CYSIF trial showed similar efficacy between infliximab and cyclosporine in steroid-refractory ASUC. Increasing steroid dose does not improve outcomes and increases toxicity.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.