Treatment outcomes for acute severe ulcerative colitis (ASUC) can be unpredictable, but clinical findings and test results help providers increase the odds for success, researchers at Johns Hopkins University School of Medicine report in Gastro Hep Advances. “Predicting how a patient with ASUC will respond to specific therapies, and whether they will need surgery, remains an elusive problem,” senior study author Joanna Melia, MD, explains. “We provide tables with the evidence for clinical characteristics that can be used to predict response to intravenous steroids, need for advanced medical therapies, and need for surgery.” Dr. Melia and her colleagues used Embase and MEDLINE to systematically review ASUC outcome predictors. They searched for full-text papers published in English between 2000 and early 2023 that presented randomized controlled trials, retrospective or prospective observational studies, or case series studying adults hospitalized with ASUC. Using data from the 48 eligible studies included in the review, they determined that key predictors of ASUC include clinical biomarkers, endoscopic scores and outcomes, and radiologic imaging findings.
Clinical Biomarkers
> C-reactive protein/albumin ratio shows promise as a biomarker for ASUC disease severity and a predictor for steroid responsiveness.
> Fecal calprotectin can distinguish ASUC from less severe disease and can strongly predict steroid responsiveness and the need for medical or surgical rescue therapy.
> Studies of serum procalcitonin’s role in ASUC show conflicting results.
> Sarcopenia is a strong predictor for rescue therapy and postoperative ASUC outcomes.
Endoscopic Scores & Outcomes
> Endoscopy, coupled with other clinical data, can help assess disease severity, guide treatment, and predict outcomes and colectomy requirements in ASUC.
> Lesion extent (eg, pancolitis, subtotal colitis, left colon) and characteristics (eg, friability, vascular patterns, bleeding, ulceration) have been linked with disease severity.
> Severity of endoscopic findings may be linked with treatment escalation from corticosteroids to rescue therapies. > Severe lesions and worse endoscopic scores have been linked with higher colectomy rates (Figure). Radiologic Imaging Studies
> Imaging results have been linked with known ASUC markers, including megacolon and mucosal islands.
> Imaging results help predict response to corticosteroids and the need for salvage therapy.
Future Research: ASUC Pathogenesis & Treatment
The pathogenesis of ASUC remains unknown, but it likely involves immune response dysfunction, genetic predisposition, and unknown environmental triggers. Patients with chronic, inflammatory ulcerative colitis typically present with urgency, abdominal pain, diarrhea, and hematochezia, the authors write. Around 1 in 4 patients with ulcerative colitis become so ill they develop ASUC and need to be hospitalized. ASUC is linked with significant morbidity, extended hospital stays, colectomy, and a roughly 1% mortality rate.
Whether medical rescue therapy beyond steroids should be considered for all patients requiring hospitalization and the optimal times to determine steroid responsiveness and to begin rescue therapy have yet to be determined.
“We need to uncover so much more to guide our ulcerative colitis treatment decisions,” Dr. Melia notes. “We need to innovate how we care for patients with ASUC safely and effectively.”
The authors acknowledge that limitations in the studies they analyzed limit their results. They consider their findings an opportunity to inform evidence-based practice and clinical decision-making and to encourage larger retrospective and prospective studies to identify and test biomarker candidates and clinical scores as they emerge. “ASUC has fascinated me since I was a medical student,” Dr. Melia says. “We have so many more ulcerative colitis therapies now, including the Janus kinase (JAK) inhibitors. The introduction of JAK inhibitors—especially in the treatment of ASUC—even though based on limited evidence, will surely impact ASUC treatment.
