Risk assessment in acute ulcerative colitis

Abstract

An episode of acute severe ulcerative colitis (UC) represents an important watershed moment during the course of the disease with a heightened risk of colectomy during and following these episodes. As such, the prompt identification and early implementation of the appropriate treatment is paramount to obtaining the best clinical outcomes for these unwell patients.A prospective database of 349 consecutive presentations of Truelove and Witts criteria qualifying moderate and severe UC was collated at a single referral centre.This resource was interrogated to identify the C-reactive protein (CRP) level that corresponds with the erythrocyte sedimentation rate (ESR) that is widely accepted as a marker of severe disease activity. A CRP threshold of ≥12mg/L was found to be an inclusive and sensitive cut off that when incorporated into the Truelove and Witts criteria, replacing the traditional ESR >30mm/h criterion, had similar performance characteristics when applied to the assessment of UC disease activity. On the level of the individual patient, the serial CRP concentration is one of the few informative and objective measures of disease acuity and treatment response that will alter management during the hospital admission. This study provides the previously lacking reassurance that baseline immunomodulator usage status need not be taken into account when interpreting the ESR or CRP levels on presentation in established UC patients not on biologic therapy.As many published IBD severity and prognostic indices in contemporary use incorporate either the ESR or CRP as objective markers of disease acuity, this study has high translatability to patients with a secure diagnosis of UC not in their initial flare.Seventeen clinical, laboratory and endoscopic variables present at the time of hospital presentation were assessed for their ability to differentiate intravenous corticosteroid therapy responders from non-responders.A risk score based on a logistic model including the admission indices of oral corticosteroid failure, bowel frequency, CRP, albumin and either disease duration or Mayo endoscopic subscore (MES) was trained on a set of 349 presentations of acute UC. This individualised risk score has the potential to inform clinicians as to the timing of treatment escalation in acute UC.