Springer Nature is making Coronavirus research free. View research | View latest news | Sign up for updates

The Management of the Hospitalized Ulcerative Colitis Patient: the Medical–Surgical Conundrum

  • 25 Accesses


Purpose of Review

In this study, we present the evidence-based management for patients hospitalized for ulcerative colitis (UC) with a special focus on the synergic approach of the two key actors of the inflammatory bowel disease multidisciplinary team (IBD-MDT): gastroenterologist and surgeon.

Recent Findings

Focused treatment by a specialized IBD-MDT and early involvement of the colorectal surgeon in the management of hospitalized UC patients is advocated. The colectomy rate has not changed over the years. Moreover, delayed surgery after admission is burden by increase complication and mortality rates. Thus, it is pivotal to identify the patients who are likely to undergo surgery, by mean of predictors of outcome, and not to prolong ineffective medical treatment. The perfect timing based on clinical close monitoring is crucial.


Up to 25% of patients with ulcerative colitis (UC) may require hospitalization. The aim of admission is to evaluate severity of the disease, exclude infections and establish proper treatment while monitoring the response. During admission, the patient has to be closely observed for the possible development of toxic megacolon or perforation, which should prompt emergency colectomy. Up to 30% of UC patients will fail to respond to initial intravenous corticosteroid. Non-responder or partial responder to medical therapy should be evaluated for timely surgery or could be considered for rescue medical therapy.

This is a preview of subscription content, log in to check access.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    •• Magro F, Gionchetti P, Eliakim R, Ardizzone S, Armuzzi A, Barreiro-de Acosta M, et al. Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 1: definitions, diagnosis, extra-intestinal manifestations, pregnancy, cancer surveillance, surgery, and ileo-anal pouch disorders. J Crohn’s Colitis. 2017. This provides provides a thorough description of evidence-based consensus on diagnosis and management of ulcerative colitis.

  2. 2.

    •• Adamina M, Angriman I, Bemelman WA, Biancone L, D’Hoore A, de van Overstraeten AB, et al. European evidence based consensus on surgery for ulcerative colitis. J Crohn’s Colitis. 2015. This provides a thorough description of evidence-based consensus on surgery for ulcerative colitis.

  3. 3.

    •• Øresland T, Bemelman WA, Sampietro GM, Spinelli A, Windsor A, Ferrante M, et al. European evidence based consensus on surgery for ulcerative colitis. J Crohns Colitis. 2015;9:4–25. This provides a thorough description of evidence-based consensus on surgery for ulcerative colitis.

  4. 4.

    Dinesen LC, Walsh AJ, Protic MN, Heap G, Cummings F, Warren BF, et al. The pattern and outcome of acute severe colitis. J Crohn’s Colitis. 2010.

  5. 5.

    Aratari A, Papi C, Clemente V, Moretti A, Luchetti R, Koch M, et al. Colectomy rate in acute severe ulcerative colitis in the infliximab era. Dig Liver Dis. 2008.

  6. 6.

    • Lynch RW, Lowe D, Protheroe A, Driscoll R, Rhodes JM, IDR A. Outcomes of rescue therapy in acute severe ulcerative colitis: data from the United Kingdom inflammatory bowel disease audit. Aliment Pharmacol Ther. 2013. This study provides a thorough description of the outcomes of rescue therapy in acute severe ulcerative colitis.

  7. 7.

    Jain S, Kedia S, Sethi T, Bopanna S, Yadav DP, Goyal S, et al. Predictors of long-term outcomes in patients with acute severe colitis: a northern Indian cohort study. J Gastroenterol Hepatol. 2018.

  8. 8.

    Farthing M. John Lennard-Jones 1927-2019: physician and gastroenterologist. Gut. 2019.

  9. 9.

    • Morar PS, Sevdalis N, Warusavitarne J, Hart A, Green J, Edwards C, et al. Establishing the aims, format and function for multidisciplinary team-driven care within an inflammatory bowel disease service: a multicentre qualitative specialist-based consensus study. Frontline Gastroenterol. 2018. This study provides a thorough description of the role of a multidisciplinary team in the management of acute severe ulcerative colitis.

  10. 10.

    Calvet X, Panés J, Alfaro N, Hinojosa J, Sicilia B, Gallego M, et al. Delphi consensus statement: quality indicators for inflammatory bowel disease comprehensive care units. J Crohn’s Colitis. 2014.

  11. 11.

    Chen JH, Andrews JM, Kariyawasam V, Moran N, Gounder P, Collins G, et al. Review article: acute severe ulcerative colitis - evidence-based consensus statements. Aliment Pharmacol Ther. 2016.

  12. 12.

    Dignass A, Lindsay JO, Sturm A, Windsor A, Colombel JF, Allez M, D’Haens G, D’Hoore A, Mantzaris G, Novacek G, Öresland T, Reinisch W, Sans M, Stange E, Vermeire S, Travis S, Van Assche G (2012) Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 2: current management. J. Crohn’s Colitis.

  13. 13.

    Gisbert JP, Chaparro M (2018) Acute severe ulcerative colitis: state of the art treatment. Best Pract. Res. Clin. Gastroenterol.

  14. 14.

    Forbes A, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, et al. ESPEN guideline: clinical nutrition in inflammatory bowel disease. Clin Nutr. 2017.

  15. 15.

    Van Gossum A, Cabre E, Hébuterne X, Jeppesen P, Krznaric Z, Messing B, et al. ESPEN guidelines on parenteral nutrition: gastroenterology. Clin Nutr. 2009.

  16. 16.

    González-Huix F, Fernández-Bañares F, Esteve-Comas M, Abad-Lacruz A, Cabré E, Acero D, et al. Enteral versus parenteral nutrition as adjunct therapy in acute ulcerative colitis. Am J Gastroenterol. 1993.

  17. 17.

    Van Assche G, Vermeire S, Rutgeerts P (2011) Management of acute severe ulcerative colitis. Gut.

  18. 18.

    Farmer RG, Easley KA, Rankin GB. Clinical patterns, natural history, and progression of ulcerative colitis - a long-term follow-up of 1116 patients. Dig Dis Sci. 1993.

  19. 19.

    Carbonnel F, Lavergne A, Lémann M, Bitoun A, Valleur P, Hautefeuille P, et al. Colonoscopy of acute colitis - a safe and reliable tool for assessment of severity. Dig Dis Sci. 1994.

  20. 20.

    Ho GT, Mowat C, Goddard CJR, Fennell JM, Shah NB, Prescott RJ, et al. Predicting the outcome of severe ulcerative colitis: development of a novel risk score to aid early selection of patients for second-line medical therapy or surgery. Aliment Pharmacol Ther. 2004.

  21. 21.

    Jakobovits SL, Travis SPL. Management of acute severe colitis. Br Med Bull. 2005.

  22. 22.

    Turner D, Walsh CM, Steinhart AH, Griffiths AM. Response to corticosteroids in severe ulcerative colitis: a systematic review of the literature and a meta-regression. Clin Gastroenterol Hepatol. 2007.

  23. 23.

    Meyers S, Lerer PK, Feuer EJ, Johnson JW, Janowitz HD. Predicting the outcome of corticoid therapy for acute ulcerative colitis: results of a prospective, randomized, double-blind clinical trial. J Clin Gastroenterol. 1987.

  24. 24.

    Molnár T, Farkas K, Nyári T, Szepes Z, Nagy F, Wittmann T (2011) Response to first intravenous steroid therapy determines the subsequent risk of colectomy in ulcerative colitis patients. J Gastrointest Liver Dis.

  25. 25.

    Leung K, Rhee G, Parlow S, Bollu A, Sabri E, MD, PhD, FRCPC JD, Murthy SK (2019) Absence of day 3 steroid response predicts colitis-related complications and colectomy in hospitalized ulcerative colitis patients. J Can Assoc Gastroenterol doi:

  26. 26.

    Argollo MC, Kotze PG, Spinelli A, Gomes TNF, Danese S. The impact of biologics in surgical outcomes in ulcerative colitis. Best Pract. Res. Clin. Gastroenterol. 2018.

  27. 27.

    Scribano ML, Papi C, Costa F, Bortoli A, Bortoluzzi F, Buscarini E, et al. Management of ulcerative colitis in a real-life setting: an Italian multicenter, prospective, observational AIGO study. Dig Liver Dis. 2019.

  28. 28.

    Shawihdi M, Dodd S, Kallis C, Dixon P, Grainger R, Bloom S, et al. Nationwide improvement in outcomes of emergency admission for ulcerative colitis in England, 2005-2013. Aliment Pharmacol Ther. 2019.

  29. 29.

    Beswick L, Rosella O, Rosella G, Headon B, Sparrow MP, Gibson PR, et al. Exploration of predictive biomarkers of early infliximab response in acute severe colitis: a prospective pilot study. J Crohn's Colitis. 2018.

  30. 30.

    Min WH, Wei J, Li J, Wang K, Ye L, Qi Y, et al. Serum procalcitonin as a potential early predictor of short-term outcomes in acute severe ulcerative colitis. Dig Dis Sci. 2019.

  31. 31.

    Al-Darmaki A, Hubbard J, Seow CH, Leung Y, Novak K, Shaheen AA, et al. Clinical predictors of the risk of early colectomy in ulcerative colitis: a population-based study. Inflamm Bowel Dis. 2017.

  32. 32.

    Tsiaoussis GI, Assimakopoulos SF, Thomopoulos KC. The writing is on the wall: the utility of mural stratification for risk stratification of hospitalized patients with severe ulcerative colitis. Dig Dis Sci. 2019.

  33. 33.

    Nguyen GC, Murthy SK, Bressler B, Lam MCW, Alali A, Toumi A, et al. Quality of care and outcomes among hospitalized inflammatory bowel disease patients: a multicenter retrospective study. Inflamm Bowel Dis. 2017.

  34. 34.

    Law CCY, Sasidharan S, Rodrigues R, Nguyen DD, Sauk J, Garber J, et al. Impact of specialized inpatient IBD care on outcomes of IBD hospitalizations: a cohort study. Inflamm Bowel Dis. 2016.

  35. 35.

    O’Connor M, Bager P, Duncan J, Gaarenstroom J, Younge L, Détré P, et al. N-ECCO consensus statements on the European nursing roles in caring for patients with Crohn’s disease or ulcerative colitis. J Crohn’s Colitis. 2013.

  36. 36.

    Millan M, Tegido M, Biondo S, García-Granero E. Preoperative stoma siting and education by stomatherapists in colorectal cancer patients: a descriptive study of 12 colorectal surgery units in Spain. Color Dis. 2009.

  37. 37.

    Forsmo HM, Pfeffer F, Rasdal A, Sintonen H, Körner H, Erichsen C. Pre- and postoperative stoma education and guidance within an enhanced recovery after surgery (ERAS) programme reduces length of hospital stay in colorectal surgery. Int J Surg. 2016.

  38. 38.

    Younis J, Salerno G, Fanto D, Hadjipavlou M, Chellar D, Trickett JP. Focused preoperative patient stoma education, prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the enhanced recovery programme. Int J Color Dis. 2012.

  39. 39.

    Hignett S, Parmar CD, Lewis W, Makin CA, Walsh CJ. Ileostomy formation does not prolong hospital length of stay after open anterior resection when performed within an enhanced recovery programme. Color Dis. 2011.

  40. 40.

    A. S, M. C, A. D, F. P. Psychological perspectives of inflammatory bowel disease patients undergoing surgery: rightful concerns and preconceptions. Curr Drug Targets. 2014.

  41. 41.

    Drossman DA, Leserman J, Li Z, Mitchell CM, Zagami EA, Patrick DL. The rating form of IBD patient concerns: a new measure of health status. Psychosom Med. 1991.

  42. 42.

    Sharpe L, Patel D, Clarke S. The relationship between body image disturbance and distress in colorectal cancer patients with and without stomas. J Psychosom Res. 2011.

  43. 43.

    Bullen TL, Sharpe L, Lawsin C, Patel DC, Clarke S, Bokey L. Body image as a predictor of psychopathology in surgical patients with colorectal disease. J Psychosom Res. 2012.

  44. 44.

    Bikhchandani J, Polites SF, Wagie AE, Habermann EB, Cima RR. National trends of 3- versus 2-stage restorative proctocolectomy for chronic ulcerative colitis. Dis Colon rectum. 2015.

  45. 45.

    Grucela A, Steinhagen RM. Current surgical management of ulcerative colitis. Mt Sinai J Med. 2009.

  46. 46.

    Cohen JL, Strong SA, Hyman NH, Buie WD, Dunn GD, Ko CY, et al. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon rectum. 2005.

  47. 47.

    Buskens CJ, Sahami S, Tanis PJ, Bemelman WA. The potential benefits and disadvantages of laparoscopic surgery for ulcerative colitis: a review of current evidence. Best Pract Res Clin Gastroenterol. 2014;28:19–27.

  48. 48.

    Schiessling S, Leowardi C, Kienle P, Antolovic D, Knebel P, Bruckner T, et al. Laparoscopic versus conventional ileoanal pouch procedure in patients undergoing elective restorative proctocolectomy (LapConPouch Trial) - a randomized controlled trial. Langenbeck’s Arch Surg. 2013.

  49. 49.

    Buskens CJ, Sahami S, Tanis PJ, Bemelman WA. The potential benefits and disadvantages of laparoscopic surgery for ulcerative colitis: a review of current evidence. Best Pract Res Clin Gastroenterol. 2014.

  50. 50.

    Leeds IL, Sundel MH, Gabre-Kidan A, Safar B, Truta B, Efron JE, et al. Outcomes for ulcerative colitis with delayed emergency colectomy are worse when controlling for preoperative risk factors. Dis Colon rectum. 2019.

  51. 51.

    Leeds IL, Truta B, Parian AM, Chen SY, Efron JE, Gearhart SL, et al. Early surgical intervention for acute ulcerative colitis is associated with improved postoperative outcomes. J Gastrointest Surg. 2017;21:1675–82.

  52. 52.

    Coakley BA, Telem D, Nguyen S, Dallas K, Divino CM. Prolonged preoperative hospitalization correlates with worse outcomes after colectomy for acute fulminant ulcerative colitis. Surg (United States). 2013.

  53. 53.

    Gallo G, Kotze PG, Spinelli A (2018) Surgery in ulcerative colitis: when? How? Best Pract. Res. Clin. Gastroenterol.

  54. 54.

    Andersson P, Söderholm JD (2009) Surgery in ulcerative colitis: indication and timing. In: Digestive Diseases.

  55. 55.

    Bemelman WA, Warusavitarne J, Sampietro GM, Serclova Z, Zmora O, Luglio G, et al. ECCO-ESCP consensus on surgery for Crohn’s disease. J Crohn’s Colitis. 2018.

  56. 56.

    Mège D, Figueiredo MN, Manceau G, Maggiori L, Bouhnik Y, Panis Y. Three-stage laparoscopic ileal pouch-anal anastomosis is the best approach for high-risk patients with inflammatory bowel disease: an analysis of 185 consecutive patients. J Crohn's Colitis. 2016.

  57. 57.

    Hicks CW, Hodin RA, Bordeianou L. Possible overuse of 3-stage procedures for active ulcerative colitis. JAMA Surg. 2013.

  58. 58.

    Alves A, Panis Y, Bouhnik Y, Maylin V, Lavergne-Slove A, Valleur P. Subtotal colectomy for severe acute colitis: a 20-year experience of a tertiary care center with an aggressive and early surgical policy. J Am Coll Surg. 2003.

  59. 59.

    Vasudevan A, Arachchi A, Scanlon C, Greenhalgh J, Van Langenberg DR. A comparison of long-term healthcare utilization and costs in patients with acute severe ulcerative colitis receiving infliximab versus early colectomy. Ther Adv Chronic Dis. 2019.

  60. 60.

    Goligher JC, De Dombal FT, Graham NG, Watkinson G. Early surgery in the management of severe ulcerative colitis. Br Med J. 1967.

  61. 61.

    Goligher JC, Hoffman DC, De Dombal FT. Surgical treatment of severe attacks of ulcerative colitis, with special reference to the advantages of early operation. Br Med J. 1970.

  62. 62.

    Roberts SE, Williams JG, Yeates D, Goldacre MJ. Mortality in patients with and without colectomy admitted to hospital for ulcerative colitis and Crohn’s disease: record linkage studies. Br Med J. 2007.

  63. 63.

    Randall J, Singh B, Warren BF, Travis SPL, Mortensen NJ, George BD. Delayed surgery for acute severe colitis is associated with increased risk of postoperative complications. Br J Surg. 2010.

  64. 64.

    Chao CY, Al Khoury A, Aruljothy A, Restellini S, Wyse J, Afif W, et al. High-dose infliximab rescue therapy for hospitalized acute severe ulcerative colitis does not improve colectomy-free survival. Dig Dis Sci. 2019;64:518–23.

  65. 65.

    Andrew RE, Lauria A, Puleo FJ, Berg A, Stewart DB. Inpatient infliximab is ineffective at preventing colectomy for steroid refractory extensive colitis. J Surg Res. 2017.

  66. 66.

    Shah SC, Naymagon S, Panchal HJ, Sands BE, Cohen BL, Dubinsky MC. Accelerated infliximab dosing increases 30-day colectomy in hospitalized ulcerative colitis patients: a propensity score analysis. Inflamm Bowel Dis. 2018.

Download references

Author information

Correspondence to Antonino Spinelli.

Ethics declarations

Conflict of Interest

Dr. Carvello acted as speaker for Takeda and Pfizer. Prof Spinelli acted as a consultant for Ethicon and Frankenman. Dr. Watfah and Dr. Włodarczyk have nothing to disclose.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Inflammatory Bowel Disease

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Carvello, M., Watfah, J., Włodarczyk, M. et al. The Management of the Hospitalized Ulcerative Colitis Patient: the Medical–Surgical Conundrum. Curr Gastroenterol Rep 22, 11 (2020).

Download citation


  • Ulcerative colitis
  • Inpatient
  • Surgery
  • Urgent management