Deep Ulcers in Acute Severe Ulcerative Colitis at Index Endoscopy Predict Corticosteroid Resistance

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Background: Acute severe ulcerative colitis (ASUC) is a life-threatening manifestation of UC that affects approximately 25% of patients. Initial management requires intravenous (IV) corticosteroids, yet about 30% of admitted patients do not respond. Objectives: This study aimed to identify endoscopic features at admission that could predict IV corticosteroid response in patients with ASUC at our center. Methods: Retrospective data were gathered from 62 patients hospitalized due to ASUC and were treated with IV corticosteroids. The Mayo Endoscopic Score (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) were collected from rectosigmoidoscopies performed at admission. Results: IV corticosteroids failed in 25.8% of patients with ASUC, necessitating the initiation of infliximab or cyclosporine. There were no significant associations between corticosteroid response and clinical or laboratory parameters, including serum albumin and C-reactive protein levels. The median UCEIS score was significantly higher in nonresponders compared to responders (7, IQR 5–8 vs. 5, IQR 5–6; p = 0.011), and it demonstrated good predictive performance for steroid non-response (area under the curve (AUC) 0.717; p = 0.005). Similarly, the MES showed a significant association with treatment outcomes (AUC 0.731; p = 0.001), with an MES = 2 displaying a 93.1% negative predictive value for IV steroid resistance. The type of ulcers (superficial vs. deep) on initial endoscopy emerged as the most robust predictor of corticosteroid response (AUC 0.771; p = 0.001). Among patients with deep ulcers observed during the initial rectosigmoidoscopy, 66.7% were nonresponders to corticosteroids, compared to only 13.3% of patients with superficial ulcers (p = 0.002). Conclusions: Endoscopic features, particularly the presence of deep ulcers, are strong predictors of corticosteroid resistance in patients with ASUC. Upon admission, a rectosigmoidoscopy should be performed, and the presence of deep ulcers should help identify patients who may benefit from rescue therapies.