Management of severe pediatric ulcerative colitis

Acute, severe ulcerative colitis (ASC) is a more common problem in children compared with adults, explained in part by the more frequent occurrence of an extensive disease phenotype in children. After clarification of the diagnosis, clinical progress during an episode of ASC can be tracked using the Pediatric Ulcerative Colitis Activity Index (PUCAI) score, which helps to guide management on a day-to-day basis and the introduction of second-line therapy where needed. The use of this score provides not only a robust definition of severe disease (PUCAI ≥65) but also provides a threshold for preparation for salvage therapy on day 3 and execution of therapy on day 5 (PUCAI scores of >45 and ≥65, respectively). The choices of medical therapy for steroid resistance are the same as those in adults - either infliximab or a calcineurin inhibitor. Surgery is reserved for non-responders to rescue therapy, or for those who develop toxic megacolon. The increased use of rescue therapy has led to a reduction in colectomy rates in recent years.