Summary : This flowchart outlines the stepwise management of acute severe ulcerative colitis (ASUC) in hospitalized patients, including diagnostic workup, initial therapy, escalation strategies, and criteria for surgery. flowchart: # Day 0 : Initial Assessment and Investigations • MODIFIED ASUC CRITERIA (box): ≥6 bowel movements along with ≥1 of: tachycardia, fever, hemoglobin <10.5 g/dL, CRP >5 mg/dL. • BASELINE INVESTIGATIONS (box): Stool microbiology (including C. difficile), assess for toxic megacolon, venous thromboembolism prophylaxis, endoscopy to rule out CMV colitis (preferably within 24 hours), surgical consultation, withhold 5-ASA. • Decision node: CDI OR CMV POSITIVE → Treat CDI or CMV Colitis (do not hold other therapies). - CDI: Fidaxomicin (200 mg BID 10-14 days) OR Vancomycin (125 mg QID 10-14 days). - CMV Colitis: If not systemic → Valacyclovir; if serum positive and diffuse inclusion bodies → Ganciclovir. • Decision node: CDI AND CMV NEGATIVE → Commence intravenous steroids without delay. - IV corticosteroid (≤60 mg methylprednisolone/day or hydrocortisone 100 mg 3-4x/day for 3-5 days), assess symptoms and CRP daily. # Day 3 : Response Assessment and Escalation • Decision node: <4 bowel movements daily for 2 days and no rectal bleeding → Transition to 40 mg oral prednisone, treat as outpatient. • Decision node: No clinical response → Initiate therapy with IV cyclosporine or infliximab, surgical consultation, daily abdominal exam, daily symptom assessment, daily CRP. - IV cyclosporine (2-4 mg/kg). - Infliximab (5 mg/kg or 10 mg/kg; consider increased dose if low serum albumin). - Tofacitinib or upadacitinib. # Day 6 : Further Response Assessment and Maintenance • Decision node: <4 bowel movements daily for 2 days and no rectal bleeding → - Maintenance with thiopurines, vedolizumab, or others (if cyclosporine used). - Maintenance with infliximab (if infliximab used). - Maintenance with tofacitinib or upadacitinib (if those used). • Decision node: If no response to cyclosporine, infliximab, tofacitinib, upadacitinib OR toxic megacolon, colonic perforation, severe refractory hemorrhage → Surgery. # Nodes : • MODIFIED ASUC CRITERIA (rectangle) • BASELINE INVESTIGATIONS (rectangle) • CDI OR CMV POSITIVE (diamond) • CDI (rectangle) • CMV Colitis (rectangle) • Not systemic (rectangle) • Serum positive and diffuse inclusion bodies (rectangle) • CDI AND CMV NEGATIVE (diamond) • IV corticosteroid (rectangle) • Day 3 (<4 bowel movements...) (diamond) • Transition to oral prednisone (rectangle) • No clinical response (diamond) • IV cyclosporine (rectangle) • Infliximab (rectangle) • Tofacitinib or upadacitinib (rectangle) • Day 6 (<4 bowel movements...) (diamond) • Maintenance with thiopurines, vedolizumab, or others (rectangle) • Maintenance with infliximab (rectangle) • Maintenance with tofacitinib or upadacitinib (rectangle) • If no response... OR toxic megacolon... (diamond) • Surgery (rectangle) # Connectors : • Arrows indicate progression from assessment to treatment, with branches for positive/negative infection status and clinical response. • Solid arrows for standard progression; dashed arrows for alternative or escalation pathways. • Merges and splits at decision nodes (diamonds). # Layout : • Three main horizontal sections: Day 0 (top), Day 3 (middle), Day 6 (bottom). • Flow proceeds left-to-right and top-to-bottom, with decision points leading to different branches. • Color coding: blue for infection management, gray for initial assessment, green for positive response, red for surgery indication. # Analysis : • The flowchart provides a clear, stepwise escalation of therapy for ASUC, integrating infection management, steroid response, and advanced therapies. • Early identification and treatment of infections (CDI, CMV) are prioritized. • Lack of response to steroids prompts rapid escalation to biologics or small molecules, with surgery as a last resort. • The structure emphasizes daily reassessment and multidisciplinary involvement (surgical consultation throughout).

This composite of four endoscopic images illustrates the pre- and post-treatment findings of ulcerative colitis in the cecum (a, c) and rectum (b, d). The pre-treatment images (a and b) demonstrate moderate to severe disease activity, characterized by a continuous loss of the typical branching vascular pattern, diffuse mucosal erythema, and numerous small erosions. Image 'a' shows white fibrinopurulent exudates in the cecum, while image 'b' highlights friability and spontaneous mucosal bleeding in the rectum. In contrast, the post-treatment images (c and d) taken after anti-TNF̡ and azathioprine therapy reveal significant mucosal healing. The mucosa appears pale and smooth with the restoration of visible submucosal vascular markings. There is evidence of mucosal scarring, and the previously noted erosions and active inflammation are absent, indicating a successful clinical response and a shift toward deep endoscopic remission.

This composite comparison chart illustrates a therapeutic response in a patient with Ulcerative Colitis (UC) over two weeks of treatment. The top row features diagnostic images from rectal Endoscopic Ultrasound (EUS), showing a reduction in Bowel Wall Thickness (BWT) from a baseline of 5.4 mm to 3.1 mm at week 2. The baseline EUS displays a thickened, hypoechoic wall, while the week 2 image shows a thinner, more defined wall architecture. The bottom row consists of clinical endoscopic photographs of the rectal mucosa. Both time points are labeled with an endoscopic Mayo (eMayo) score of 3, signifying severe disease activity. The baseline endoscopy shows extensive mucosal erythema, loss of vascular pattern, and spontaneous bleeding (friability). The week 2 follow-up shows persisting inflammation but with a visible reduction in active hemorrhage and superficial ulceration. This educational material demonstrates the use of BWT as a sensitive early biomarker for monitoring pharmacological response to biological therapy (such as adalimumab) in inflammatory bowel disease, even when clinical endoscopic scores remain elevated.

This medical graphic is a combined timeline and clinical image series documenting the management of acute severe ulcerative colitis in a pediatric patient over an 8-month period. The top portion is a Timeline/Progression diagram illustrating sequential pharmacological interventions including intravenous (IVCS) and oral (POCS) corticosteroids, infliximab (orange triangles), methotrexate (yellow pentagons), vedolizumab (green diamonds), and tofacitinib (horizontal red arrow). It also tracks clinical supportive care like total parenteral nutrition (TPN) and blood transfusions (small red vertical arrows). Disease activity is quantified via Pediatric Ulcerative Colitis Activity Index (PUCAI) scores, which range from 75 during peak severity to 0 at clinical remission. The bottom portion contains three Diagnostic Images (endoscopy frames) corresponding to different stages of treatment. The initial frames show significant pathological features including intense mucosal erythema, loss of vascular patterns, and friability with luminal blood. The final frame demonstrates mucosal healing with restored vascular markings and absence of active inflammation following the initiation of tofacitinib therapy. This visual summary is intended for gastroenterology specialists to illustrate the management of refractory pediatric inflammatory bowel disease.