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Catastrophe prevention: Acute severe ulcerative colitis

Acute severe ulcerative colitis (ASUC) is a poor prognostic event in the life of a patient with ulcerative colitis (UC). It is associated with an increased risk of colectomy and can be accompanied by the development of systemic complications including anemia, deep vein thrombosis (DVT), medication adverse events, and nutritional deficiencies. Apart from death, which fortunately is extremely rare, the definition of a catastrophic event is debatable. However, it is clear that any of the above outcomes or adverse events could be perceived as catastrophic depending on the person assessing the incident. There are numerous local and international guidelines on the management of patients with ASUC that aim to reduce complications and improve patient outcomes. The Crohn’s and Colitis Australia (CCA) Inflammatory Bowel Disease (IBD) Audit examined the characteristics and outcomes of admissions for UC across Australian hospitals. It emphasized certain deficiencies in the management of patients with UC and highlighted room for improvement. ASUC is a severe disease requiring admission to a hospital with appropriate medical, surgical, and allied health teams to manage the condition. Although short-term outcomes and early colectomy rates have improved in the era of biologic treatments, rates of mediumto long-term colectomy have not changed. Therefore, a colorectal surgeon and stomal therapy nurse must be available to educate the patient about their care and the possibility of future procedures including definitive surgery. Guidelines recommend having a multidisciplinary team comprising a gastroenterologist, colorectal surgeon, gastroenterology nurse, dietitian, pharmacist, and a stomal therapist; however, fewer than half of Australian units have access to this type of multidisciplinary team where complex IBD cases can be discussed, and fewer than a quarter of units have a partial IBD service with a dedicated IBD nurse and a named clinical lead. Clinicians need to acknowledge if they have the recommended resources to manage these patients and, if not, to initiate a prompt referral to an appropriate service. Management guidelines provide clear recommendations for required investigations, treatment timing, and indications for medical and surgical therapy escalation. However, the daily management of an admitted patient is often overseen by junior medical staff who may not have the knowledge of, or access to, these guidelines. Having a documented and easily available clinical pathway or protocol can reduce hospital complications without impacting on length of stay or hospital costs. The CCA IBD Audit suggested that only 28% of units had a protocol or clinical pathway in place for ASUC. Documented pathways should include the timing of investigations including stool examination and sigmoidoscopy, the use of DVT prophylaxis even in the presence of per-rectal bleeding, and the timing of assessment of response to medical and surgical therapy recognizing that early and prompt escalation is essential. They should also address any potential barriers that may be encountered such as dispensing of rescue medications outside of business hours. In the event of successful therapy and improved disease status enabling discharge, appropriate follow up is essential and must include documented treatment plans, infusion booking dates, and immunosuppression monitoring to ensure continued clinical improvement and to maintain the long-term health and safety of the patient.