Inpatient Clinical Pathway for Assessment and Management
of Children with Acute Severe/Fulminant Ulcerative Colitis

Treatment Considerations
  • PUCAI Daily
    • Assess Severity
  • Flexible sigmoidoscopy
    • Exclude infection (CMV, C. difficile)
    • Assess severity of colitis
    • Risk of full colonoscopy may be too high
  • Infliximab (IFX)
    • Approximately 10mg/kg/dose may be appropriate
  • Surgical intervention
    • Consult IBD team
  • Antibiotics
    • Triple/quadruple regimen
  • Pain management
    • Significant/uncontrolled pain may be a sign of toxic megacolon
    • Narcotics contraindicated
  • Steroids
    • Inpatients on IV methylprednisolone
    • Consider oral steroids if PUCAI < 35 at any time during treatment
Initial Assessment:
  • History and Physical, Initial Diagnostic Testing
  • Consultation with GI Fellow
Does not meet criteria for
Acute Severe Ulcerative Colitis
Treat as clinically indicated
Abdominal X-ray
Surgery consultation
Meets criteria for Acute Severe/Fulminant
Ulcerative Colitis
Inpatient Management of Acute Severe Ulcerative Colitis
(on GI service)
Clinical guidelines recommend initiation of second-line therapy if there is no response to IV corticosteroids noted within 3-10 days. Guidelines recommend using the third and fifth IV steroid day to determine need for therapy escalation.
Treatment Day 1
  • Methylprednisolone 1 mg/kg/dose twice daily up to 24 mg twice daily
  • May continue regular diet as tolerated
Laboratory Testing
Severity Assessment
Discuss treatment options with family
Treatment Day 3
Recheck labs if not done in last 48 hrs: CBC, CRP, consider CMP
PUCAI < 35
  • Consider oral steroids
PUCAI 35-45
  • Consider flexible sigmoidoscopy
  • Continue therapy and monitoring
PUCAI > 45
  • Prepare for IFX
  • Schedule flexible sigmoidoscopy
  • Surgical consult
Treatment Day 5
PUCAI < 35
  • Consider oral steroids
PUCAI 35-65
  • Can continue steroids
  • Monitor for 2-5 more days
  • Consider IFX
PUCAI > 65
  • Administer IFX
  • Consider colectomy
Post-IFX Treatment
PUCAI < 35
  • Consider oral steroids
PUCAI 35-65
  • Can continue steroids
  • Monitor for 2-5 more days
PUCAI > 65
or 35-65
for > 2-5 days
Posted: February 2017
Revised: July 2020
Authors: E. Maxwell, MD; S. Fusillo, MD; A. Grossman, MD; J. Crawford, CNS; K. Wilson, RN; M. Downing