Clinical Scenario:
A 13-year-old boy is admitted with a 6-week history of progressively worsening diarrhea. He is passing 10–12 bloody stools daily, including nocturnal stools, associated with urgency and tenesmus. He has lost 6 kg over the past two months and complains of fatigue. Examination reveals pallor, tachycardia (HR 118/min), and mild diffuse abdominal tenderness. His BMI is below the 5th percentile.
Investigations:
Hemoglobin: 8.5 g/dL
ESR: 65 mm/hr
CRP: 48 mg/L
Serum albumin: 2.6 g/dL
Stool cultures: Negative
Fecal calprotectin: >2000 μg/g
Colonoscopy demonstrates continuous circumferential inflammation extending from the rectum to the splenic flexure with spontaneous mucosal bleeding and multiple deep ulcerations.
He is started on intravenous hydrocortisone. After 5 days of therapy, he continues to pass 9–10 bloody stools daily and his Pediatric Ulcerative Colitis Activity Index (PUCAI) score remains 75.
What is the most appropriate next step in management?
A. Azathioprine
B. Infliximab
C. Mesalamine (oral and rectal)
D. Methotrexate
E. Oral prednisolone
Correct answer & Explanation:
Correct Answer: B. Infliximab
Discussion: Ulcerative colitis
This child has Acute Severe Ulcerative Colitis (ASUC) as suggested by:
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Frequent bloody diarrhea (>6/day)
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Nocturnal stools
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Urgency and tenesmus
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Significant weight loss
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Anemia and hypoalbuminemia
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Elevated inflammatory markers
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Colonoscopy showing continuous disease beginning from the rectum without skip lesions
The patient was appropriately started on intravenous hydrocortisone, which is first-line treatment for ASUC.
A PUCAI >65 on day 5 of intravenous corticosteroid therapy indicates failure of first-line treatment and should prompt second-line medical therapy or colectomy. In such patients, escalation to rescue therapy is required.
Infliximab is an established second-line rescue therapy for steroid-refractory pediatric acute severe ulcerative colitis. Other accepted options include tacrolimus, cyclosporine, and colectomy, depending on the clinical circumstances and local expertise.
Why the Other Options Are Incorrect
A. Azathioprine
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Slow onset of action (several weeks to months).
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Used for maintenance of remission, not induction in acute severe disease.
C. Mesalamine (oral and rectal)
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Appropriate for mild-to-moderate ulcerative colitis.
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Inadequate for steroid-refractory ASUC.
D. Methotrexate
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Limited role in ulcerative colitis and not recommended as rescue therapy.
E. Oral prednisolone
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Failure of IV corticosteroids indicates need for escalation, not continuation of steroid therapy by another route.
Key Examination Pearl
A child with acute severe ulcerative colitis who has a PUCAI ≥65 after 3–5 days of intravenous hydrocortisone has steroid-refractory disease, and the single best next treatment is infliximab. Azathioprine should never be chosen as rescue therapy because of its delayed onset of action.
References
- Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, de Carpi JM, Bronsky J, et al. Management of paediatric ulcerative colitis, part 2: acute severe colitis—an evidence-based consensus guideline from ECCO and ESPGHAN. J Pediatr Gastroenterol Nutr. 2018;67(2):292-310.
- Turner D, Travis SP, Griffiths AM, Ruemmele FM, Levine A, Benchimol EI, et al. Consensus for managing acute severe ulcerative colitis in children: a systematic review and joint statement from ECCO, ESPGHAN, and the Porto IBD Working Group of ESPGHAN. Am J Gastroenterol. 2011;106(4):574-588.
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