Clinical scenario:
A 13-year-old boy with a 6-month history of intermittent bloody diarrhea presents with worsening symptoms over the past week. He is passing 10–12 bloody stools daily and complains of crampy abdominal pain and tenesmus. On examination, he appears pale and lethargic. His temperature is 38.6°C, heart rate is 118/min, and the abdomen is mildly distended with diffuse tenderness but no guarding. Laboratory investigations reveal: hemoglobin 8.9 g/dL, ESR 68 mm/hour, C-reactive protein 74 mg/L, serum albumin 2.8 g/dL, and stool cultures are negative.
What is the most appropriate initial treatment?
A. Azathioprine
B. Infliximab
C. Intravenous corticosteroids
D. Oral mesalazine
E. Total colectomy
Correct answer & Explanation:
Correct Answer: C. Intravenous corticosteroids
Explanation
This child has acute severe ulcerative colitis (ASC).
The diagnosis is supported by:
- Frequent bloody diarrhea (>6 stools/day)
- Fever
- Tachycardia
- Anemia
- Elevated inflammatory markers
- Hypoalbuminemia
- Negative stool cultures, making infectious colitis less likely
According to ESPGHAN/ECCO guidelines, the first-line treatment for acute severe ulcerative colitis is intravenous corticosteroids after excluding infectious causes.
Response should be assessed after 3–5 days using the Pediatric Ulcerative Colitis Activity Index (PUCAI). Children who fail intravenous corticosteroids require second-line rescue therapy (e.g., infliximab or calcineurin inhibitors) or surgical consultation.
Why the other options are incorrect
A. Azathioprine
Not appropriate for induction because its onset of action is delayed (weeks to months). It is mainly used for maintenance therapy.
B. Infliximab
Recommended as rescue therapy for children who fail intravenous corticosteroids, not as the initial treatment.
C. Intravenous corticosteroids
Correct. They are the recommended first-line therapy for acute severe ulcerative colitis.
D. Oral mesalazine
Appropriate for mild to moderate ulcerative colitis but inadequate for acute severe disease.
E. Total colectomy
Reserved for refractory disease, complications (e.g., perforation, uncontrolled hemorrhage), or failure of medical rescue therapy.
Learning Point
Acute severe ulcerative colitis in children is a medical emergency.
Key principles include:
- Exclude infectious colitis (especially Clostridioides difficile)
- Start intravenous corticosteroids
- Reassess after 3–5 days
- If steroid-refractory, initiate infliximab (or another guideline-supported rescue therapy) and involve pediatric surgery early.
