A 28-year-old woman presents with 8 weeks of bloody diarrhoea (8–10 episodes/day), tenesmus, and crampy abdominal pain. CRP is 48 mg/L. Stool cultures are negative. Flexible sigmoidoscopy shows continuous mucosal inflammation from the rectum to the splenic flexure with loss of vascular pattern. Biopsy shows crypt abscesses and chronic changes. She scores Mayo 10 (severe UC). She is started on IV methylprednisolone. On day 5 she has persistent 8 stools/day with CRP 32 and temperature 37.8°C. The MOST appropriate next step is:

• A Infliximab or cyclosporine rescue therapy ✓
• B Continue IV steroids for 3 more days
• C Oral prednisolone and mesalazine escalation
• D Emergency colectomy without medical rescue

Explanation

Severe UC (Truelove and Witts criteria) failing to respond to IV corticosteroids by day 3 (Oxford criteria: >8 stools/day or 3–8 stools/day with CRP >45 mg/L) identifies steroid-refractory disease requiring rescue therapy or colectomy. This patient meets Truelove-Witts criteria for persistent severe UC at day 5. Rescue therapy with infliximab (5 mg/kg IV) or cyclosporine (2 mg/kg IV) avoids emergent colectomy in ~50% of cases. ECCO guidelines recommend the decision for rescue vs surgery by day 3–5. Continuing steroids beyond day 7 without rescue increases surgical risk.

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

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Written and medically reviewed by the StethoPrep medical team.