Ulcerative Colitis

Mild-ModerateDistal Colitis

Mild-ModerateExtensive Colitis Severe Colitis

Criteria for Evaluating the Severity of Ulcerative Colitis (Truelove & Witts)

Topical 5-ASA

AND/OR

Oral 5-ASA

Topical steroidOR

Remission

NO

Oral steroids (prednisone)

Maintenance(5-ASA)

YES

Oral 5-ASA +Topical 5-

ASA

Glucocorticoids (PO prednisone)

YES

Remission

NO

Maintenance

Taper steroidsYES

NO

+Azathioprine or 6-MP

Failure

Glucocorticoids (IV methylprednisone)

R/O C.difficile

Response after 7-10 days

Maintenance(Azathioprine)

IV Cyclosporine + Azathioprine

NO YES

Failure

+ infliximab

•exsanguination hemorrhages•frank perforation•carcinoma

SurgeryYES

•DEXA scan•bisphosphonate•calcium/VitD

Consider in all patients

Recurrent Symptoms?(steroid dependent)

SurgeryFailure

+ infliximab

Failure

Response & steroid sparing

Mild Moderate SevereBowelMovements <4 per day 4–6 per day >6 per day

Blood in Small Moderate Severe stool Fever None <37.5°C mean >37.5°C mean Tachycardia None <90 mean pulse >90 mean pulse Anemia Mild >75% < 75% Sedimentation <30 mm >30 mm rate

Truelove SC, Witts LJ. Cortisone in ulcerative colitis: Final report on a therapeutic trial. BMJ 1955;2:1041-8

Topical 5-ASA •Rowasa•Canasa

Oral 5-ASA•sulfasalazine

Azulfidine•mesalamine

Lialda Dipentum Colazide

Asacol

•Cortifoam or •Cortenema, Colocort

Topical steroidshydrocortisone

AND/OR

Anti-TNF α

infliximab adalimumab(Crohn’s only)