Ulcerative Colitis Flare-Up: Repeat Presentation

Clinical Scenario

Andrew Patel, 35, books a video consultation requesting steroids for an ulcerative colitis flare. He was discharged from hospital 3 weeks ago after treatment for a UC flare with IV hydrocortisone followed by oral prednisolone 40mg, tapering to his current dose of 20mg. His mesalazine was increased. Despite this, he is now having 9 bloody stools daily, abdominal pain and cramping, fevers, and has lost 3-4kg in 2 weeks. He feels generally unwell and weak. He is requesting a steroid dose increase from his GP rather than returning to hospital.

What This Case Tests

Recognising a severe UC flare using Truelove and Witts criteria; identifying steroid-refractory disease (flare on a prednisolone taper); understanding that this requires urgent hospital assessment, not primary care management; communicating the urgency to a patient who wants to avoid readmission; navigating a patient who has a specific request (more steroids) that is insufficient for the severity of their disease.

Common Mistakes Trainees Make

The three most common mistakes are: increasing the prednisolone dose and managing in primary care (this is a severe flare that has failed steroid treatment — it needs urgent hospital assessment for possible IV steroids, rescue therapy with infliximab or ciclosporin, and potentially surgery), not recognising the severity using Truelove and Witts criteria (9 bloody stools, fever, weight loss, and failure to respond to oral steroids meets the criteria for severe disease), and not assessing for surgical emergency indicators (toxic megacolon, perforation).

The Consultation Challenge

Andrew does not want to go back to hospital. He was only discharged 3 weeks ago and the prospect of readmission is demoralising. But the clinical picture is clear: he has a severe UC flare that is failing steroid treatment, and this requires urgent hospital assessment.

Apply the Truelove and Witts criteria. Severe UC is defined as: 6 or more bloody stools per day (Andrew has 9), PLUS at least one of: pulse >90, temperature >37.8, haemoglobin <105 g/L, ESR/CRP elevated. Andrew has fevers and is systemically unwell. He meets the criteria for severe disease.

The critical clinical issue is steroid-refractory disease. Andrew was started on IV hydrocortisone in hospital, stepped down to oral prednisolone 40mg, and is now flaring on a 20mg taper. This means oral steroids at the current dose are not controlling his disease. Simply increasing the prednisolone is not the answer — he needs assessment for rescue therapy (infliximab or ciclosporin) or surgical consideration.

Screen for emergency complications. Toxic megacolon can complicate severe UC and is a surgical emergency. Ask about: worsening abdominal distension, sudden reduction in stool frequency with worsening pain (bowel dilation), high fever, and tachycardia. If any of these are present, this is a 999 emergency, not a same-day referral.

Communicate the urgency compassionately. Andrew does not want to be readmitted. Validate this: "I completely understand that the last thing you want is to go back to hospital. But I have to be honest with you — what you are describing tells me that the current treatment is not controlling your colitis, and the level of severity you are at now needs specialist assessment that I cannot provide safely from primary care."

Arrange urgent same-day gastroenterology assessment — either through the IBD helpline (most hospitals have one), the on-call gastroenterology team, or direct to acute medical assessment. Do not simply increase the steroids and review in a week.

Time check: Spend the first 3 minutes on symptom assessment and Truelove and Witts criteria. By minute 5, identify this as severe steroid-refractory disease. Screen for surgical emergency between minutes 6-7. Communicate the need for hospital assessment between minutes 8-10. Use the remaining time for arranging the urgent referral and supporting Andrew.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you systematically apply the Truelove and Witts criteria (stool frequency, blood, fever, pulse, haemoglobin), assess the response to current treatment (steroid-refractory on taper), screen for complications (toxic megacolon, perforation), and take a thorough IBD history (current medications, adherence, previous flare pattern). A trainee who does not use severity criteria will score poorly.

Clinical Management and Medical Complexity: Examiners expect recognition that this is steroid-refractory severe UC requiring urgent hospital assessment, not primary care dose adjustment. They look for knowledge of the escalation pathway (IV steroids, then rescue therapy with infliximab or ciclosporin, then surgery), awareness of the IBD helpline as an access route, and understanding of why simply increasing oral prednisolone is inappropriate. This is a case where recognising your limits as a GP is the management.

Relating to Others: Examiners assess whether you acknowledge Andrew's reluctance to be readmitted, communicate the urgency clearly without causing panic, and support him through the decision. The patient should understand why hospital assessment is necessary and feel that you are acting in his best interests, even though the outcome is not what he requested.

Example Opening

Strong opening: "Hello Andrew, I can see you are struggling again with your colitis. Before we talk about steroids, I need to understand exactly what is happening right now — can you tell me about your symptoms over the last few days?"

When communicating urgency: "Andrew, I understand you do not want to go back to hospital, and I really wish I could manage this from here. But I have to be straight with you — nine bloody stools a day with fevers and weight loss while you are already on steroids tells me this flare is more severe than what I can safely treat in primary care. The steroids you are on should be controlling this, and the fact that they are not means we need a different approach that only the hospital team can provide."

Avoid: "I will increase your prednisolone to 40mg and review you in a week." (Inappropriate for severe steroid-refractory UC and potentially dangerous).

How This Appears in the SCA

This case tests whether you can recognise a medical emergency presenting as a routine GP request. Andrew wants more steroids — but giving them would be clinically inappropriate and potentially dangerous. Examiners assess whether you apply severity criteria correctly, recognise steroid-refractory disease, and arrange urgent hospital assessment despite the patient's reluctance.

Key Statistic

Acute severe ulcerative colitis carries a mortality rate of approximately 1-2% per admission. Approximately 30% of patients with acute severe UC who fail IV steroid therapy require colectomy. Early escalation to rescue therapy (infliximab or ciclosporin) within 3-5 days of steroid failure improves outcomes and reduces the need for surgery.

Relevant Guidelines

• NICE NG130: Ulcerative colitis — management
• Truelove and Witts severity criteria
• British Society of Gastroenterology (BSG) guideline on management of acute severe UC.

Frequently Asked Questions

What are the Truelove and Witts criteria for severe ulcerative colitis?

Severe UC is defined as 6 or more bloody stools per day PLUS at least one of: pulse greater than 90 bpm, temperature greater than 37.8 degrees, haemoglobin less than 105 g/L, or ESR/CRP significantly elevated. This is a validated severity scoring system that guides management — severe disease requires inpatient treatment, not outpatient dose adjustment. Andrew meets these criteria clearly.

What does steroid-refractory UC mean and why does it matter?

Steroid-refractory UC means the disease is not responding adequately to steroid treatment. When a patient flares while on a prednisolone taper (as Andrew is), it indicates that steroids alone cannot control the inflammation. Simply increasing the dose rarely works and exposes the patient to additional steroid side effects. The next step is rescue therapy — typically infliximab or ciclosporin administered in hospital — or surgical consultation. This escalation decision requires specialist input.

Should I ever increase oral steroids for a UC flare in primary care?

For a mild-to-moderate flare in a patient not already on steroids, initiating prednisolone 40mg with a tapering regimen in primary care is appropriate per NICE NG130. However, for a patient who is already on steroids and flaring (steroid-refractory), or for a patient meeting severe criteria, increasing the dose is insufficient — hospital assessment is required. Knowing this distinction is what the examiner is testing.

What emergency complications should I screen for in severe UC?

Toxic megacolon: sudden improvement in diarrhoea with worsening abdominal distension and pain (paradoxical improvement as the colon dilates and stops functioning), high fever, tachycardia. Perforation: sudden severe abdominal pain, rigidity, peritonism. Both are surgical emergencies requiring immediate hospital transfer. Ask specifically about abdominal distension and any sudden change in bowel pattern.

How do I arrange urgent hospital assessment for a UC flare?

Most hospitals with IBD services have an IBD helpline or advice line — call directly to arrange same-day assessment. Alternatively, contact the on-call gastroenterology registrar through the hospital switchboard. If the patient is acutely unwell (septic, peritonitic, or haemodynamically unstable), send directly to A&E via ambulance. Do not rely on a written referral through standard channels for urgent IBD presentations.