Guideline sources The following summarized guidelines for the evaluation and management of ulcerative colitis (UC) are prepared by our editorial team based on guidelines from the European Society for Clinical Nutrition and Metabolism (ESPEN 2023), the American Gastroenterological Association (AGA 2023; 2020; 2017), the European Crohn's and Colitis Organisation (ECCO 2022; 2015), the World Society of Emergency Surgery (WSES/AAST 2021), the American College of Gastroenterology (ACG 2021; 2019; 2017; 2010), the American Society of Colon and Rectal Surgeons (ASCRS 2021; 2014), the American College of Radiology (ACR 2021), and the Healthcare Infection Society (HIS/BSG 2018). 1 2 3 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 19 19 20 21 22 Definition https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 1/18 6/29/23, 3:46 AM Ulcerative colitis Pathway UC is a chronic relapsing-remitting IBD characterized by superficial mucosal ulceration extending from the rectum to proximal colon. 18 Epidemiology The pathogenesis of UC is multifactorial and involves mutations in susceptibility genes, abnormalities in gut microbiota composition and host-microbiome interactions, as well as abnormalities in humoral and cellular adaptive immunity. 19 Pathophysiology The highest incidence and prevalence of IBD are seen in the populations of Northern Europe and North America and the lowest in continental Asia. In the United States, the incidence of UC is estimated at 8.8 cases per 100,000 person-years, while the prevalence is estimated at 286.3 persons per 100,000 population. 19 20 Disease course Inflammation and ulceration of the colonic mucosa may result in clinical manifestations of proctitis, proctosigmoiditis, left-sided colitis, pancolitis, severe rectal bleeding, toxic megacolon, and colorectal cancer, in addition to extraintestinal complications. 19 Prognosis and risk of recurrence Over 10-years, 50-55% of patients remit, approximately 37% follow a chronic intermittent course, and 6% develop a chronic continuous course. An estimated 20-30% of patients require colectomy after 25 years of disease activity. The standardized mortality ratio of patients with UC, as compared with the general population, is estimated at 2.78 (95% CI, 1.48-4.75). 21 22 Calculator Truelove and Witts index for ulc Guidelines 1. Screening and diagnosis Clinical presentation: suspect the diagnosis of UC in patients with hematochezia and urgency. E Diagnosis: diagnose UC based on a set of modalities including clinical, biochemical, endoscopic, radiological, and histological diagnostics rather than a single reference standard. B 2. Classification and risk stratification https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 2/18 6/29/23, 3:46 AM Ulcerative colitis Pathway Classification and severity assessment: Categorize disease extent in patients with UC as: Situation Guidance Within 18 cm of the anal verge, distal to the rectosigmoid junction Proctitis Extending from the sigmoid to the splenic flexure Left-sided colitis Beyond the splenic flexure. E Extensive colitis Determine disease severity based on: Situation Guidance Bleeding and normalization of bowel habits Patient-reported outcomes Endoscopic assessment including extent and severity Inflammatory burden Markers of inflammation Need for hospitalization Disease course Need for corticosteroids Failure to respond to medications Functionality Disease impact Quality of life. E 3. Diagnostic investigations Infectious workup: As per WSES 2021 guidelines, exclude infectious causes, especially C. difficile and CMV, in patients with suspected IBD flare. B As per ACG 2019 guidelines, exclude infectious etiologies at the time of diagnosis. E Show 2 more Fecal calprotectin: consider obtaining fecal calprotectin as noninvasive marker of disease activity and to assess response to therapy and relapse in patients with UC. E Antibody testing: Avoid serologic antibody testing to establish or rule out a diagnosis of UC. D Avoid serologic antibody testing to determine the prognosis of UC. D Diagnostic imaging: As per ACR 2021 guidelines: https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 3/18 6/29/23, 3:46 AM Ulcerative colitis Pathway Obtain any of the following as the initial imaging in patients with suspected proctitis or pouchitis: MR enterography MRI of pelvis without and with IV contrast CT enterography CT of pelvis with IV contrast. B Obtain any of the following as the initial imaging in patients with suspected complication postproctectomy or coloproctectomy or colectomy with pouch or other anastomosis: MRI of pelvis without and with IV contrast CT of abdomen and pelvis with IV contrast CT of pelvis with IV contrast. B As per WSES 2021 guidelines, obtain IV contrast-enhanced CT for the evaluation of acute abdomen in patients with IBD in the emergency setting, to exclude the presence of intestinal perforation, stenosis, bleeding and abscesses and to help guide decision making for immediate surgery or initial conservative management. B Show 5 more Assessment of disease activity: Assess UC disease activity in an urgent clinical situation with the following laboratory tests: CBC, including Hgb, WBC, and platelet count ESR, CRP serum electrolytes liver enzymes serum albumin renal function fecal calprotectin. B Assessment of acute abdomen: Obtain the following laboratory tests in the assessment of acute abdomen in patients with IBD: CBC electrolytes liver enzymes inflammatory biomarkers (such as ESR and CRP) serum albumin and pre-albumin (to assess nutritional status and degree of inflammation). B Evaluation of anemia: obtain anemia workup (including at least RBC indices such as red cell distribution width and MCV, reticulocyte count, differential blood cell count, serum ferritin, transferrin saturation, and CRP concentration) if the Hgb is below normal. Include the following in a more extensive workup: serum concentrations of vitamin B12, folic acid, haptoglobin, the percentage of hypochromic red cells, reticulocyte Hgb, LDH, soluble transferrin receptor, creatinine, and urea. B Show 8 more Screening for osteoporosis: https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 4/18 6/29/23, 3:46 AM Ulcerative colitis Pathway As per ESPEN 2023 guidelines, monitor serum 25-hydroxyvitamin D status in adult and pediatric patients with active IBD on corticosteroid treatment or suspected vitamin D deficiency. Initiate calcium/vitamin D supplementation, if required, to prevent low bone mineral density. Manage osteopenia and osteoporosis according to current osteoporosis guidelines. B As per ACG 2017 guidelines, screen for osteoporosis with bone mineral density testing at the time of diagnosis and periodically after diagnosis in patients with UC and conventional risk factors for abnormal bone mineral density. B Screening for anxiety and depression: screen patients with UC for coexistent anxiety and depressive disorders and provide with resources to address these conditions if identified. E 4. Diagnostic procedures Flexible sigmoidoscopy: As per WSES 2021 guidelines, perform sigmoidoscopy for intra-luminal assessment of distal IBD activity, bleeding source identification and biopsies in an acute setting, if available. B As per ACG 2019 guidelines, obtain a flexible sigmoidoscopy within 72 hours, and preferably within 24 hours of admission in all patients with acute severe UC. This should be used to assess endoscopic severity of inflammation and to obtain biopsies to evaluate for CMV colitis. E Lower gastrointestinal endoscopy: Obtain colonoscopy with intubation of the ileum and biopsies of affected and unaffected areas should be obtained to confirm the diagnosis of UC, with review of pathological specimens by a pathologist with expertise in gastrointestinal pathology when possible. E Avoid further evaluation of the stomach and small bowel by upper endoscopy and cross- sectional imaging in patients with a normal terminal ileum, is not needed unless there are other symptoms or findings to suggest proximal gastrointestinal involvement or a diagnosis of Crohn's disease rather than UC. D 5. Medical management General principles: As per AGA 2020 guidelines: Use infliximab, adalimumab, golimumab, vedolizumab, tofacitinib, or ustekinumab in adult outpatients with moderate-to-severe UC. B Use tofacitinib in adult outpatients with moderate-to-severe UC who are na ve to biologic agents only in the setting of a clinical or registry study. B As per ACG 2019 guidelines, UC is a chronic condition for which therapy is required to induce and maintain remission; therapeutic decisions should be categorized into those for (i) induction and (ii) maintenance, with a goal of obtaining and maintaining a steroid-free remission. E Show 2 more https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 5/18 6/29/23, 3:46 AM Ulcerative colitis Pathway Treatment targets: target restoration of normal bowel frequency and control of the primary symptoms of bleeding and urgency as part of the initial treatment of UC. E Show 2 more Induction of remission, mild-to-moderate disease: As per ECCO 2022 guidelines, initiate 5-ASA at a dose of 2 g/day for the induction of remission in patients with mildly-to-moderately active UC. B Show 6 more As per ACG 2019 guidelines, initiate rectal 5-ASA enemas at a dose of at least 1 g/d (preferred over rectal steroids) for induction of remission In patients with mildly active left- sided UC. B Show 4 more Induction of remission, moderate-to-severe disease: As per ECCO 2022 guidelines, initiate oral prednisolone for the induction of remission in nonhospitalized patients with moderately-to-severely active UC. B As per AGA 2020 guidelines, consider infliximab or vedolizumab, rather than adalimumab, for induction of remission in adult outpatients with moderate-to-severe UC who are na ve to biologic agents. C Show 8 more As per ACG 2019 guidelines: Use budesonide delayed- or ER for induction of remission in patients with moderately active UC. B Consider nonsystemic corticosteroids before the use of systemic therapy in patients with moderately active UC. E As per ACG 2019 guidelines, administer oral systemic corticosteroids to induce remission in patients with moderately to severely active UC of any extent. B Show 5 more Maintenance of remission, mild-to-moderate disease: As per ECCO 2022 guidelines, initiate oral 5-ASA at a dose of 2 g/day for the maintenance of remission in patients with UC. B Show 2 more As per ACG 2019 guidelines, avoid using systemic corticosteroids for maintenance of remission in patients with UC. D Show 2 more Maintenance of remission, moderate-to-severe disease: As per ECCO 2022 guidelines, initiate anti-TNF agents (infliximab, adalimumab, or golimumab) for the maintenance of remission in patients with UC responded to induction therapy with the same drug. B Show 5 more As per AGA 2020 guidelines, consider thiopurine monotherapy for maintenance of remission in adult outpatients with moderate-to-severe UC in remission. C Show 6 more https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 6/18 6/29/23, 3:46 AM Ulcerative colitis Pathway As per ACG 2019 guidelines, avoid using systemic corticosteroids for maintenance of remission in patients with UC. D Show 5 more Maintenance of remission (antibiotics): insufficient evidence to recommend an antibiotic regimen for the maintenance of remission in patients with UC. I Management of inadequate treatment response (mild-to-moderate disease): consider changing to an alternate 5-ASA formulation to induce remission in patients with mildly active UC who fail to reach remission with appropriately dosed 5-ASA (at least 2 g/d oral 5-ASA and/or at least 1 g/d rectal 5-ASA). C Show 2 more Management of inadequate treatment response, moderate-to-severe disease: As per ECCO 2022 guidelines, initiate any of the following for the induction of remission in patients with moderate-to-severe UC with inadequate response or intolerance to conventional therapy: anti-TNF agents, such as infliximab, adalimumab, and golimumab B vedolizumab B tofacitinib B ustekinumab. B As per ACG 2019 guidelines, assess patients experiencing nonresponse or loss of response to therapy with therapeutic drug monitoring to identify the reason for lack of response and whether to optimize the existing therapy or to select an alternate therapy. E Show 2 more Management of acute severe ulcerative colitis: As per ESPEN 2023 guidelines, insufficient evidence to recommend an antibiotic regimen for the treatment of active disease, including acute severe disease, in patients with UC. I As per WSES 2021 guidelines, consider evaluating all hemodynamically stable patients presenting with acute severe UC in a multidisciplinary approach with the gastroenterologist to decide on options for initial medical treatment. C Show 3 more As per AGA 2020 guidelines, consider IV methylprednisolone dose equivalent of 40 to 60 mg/day, rather than higher doses of IV corticosteroids, in hospitalized adult patients with acute severe UC. C Show 3 more As per ACG 2019 guidelines, avoid the routine use of broad-spectrum antibiotics in the management of acute severe UC. Administer methylprednisolone (60 mg/day) or hydrocortisone (100 mg TID or QID) to induce remission in patients with acute severe UC (strong recommendation, low quality of evidence). D Show 8 more Management of complications: evaluate medical treatment in patients with IBD presenting with acute abdominal pain and disease activity in a multidisciplinary approach, involving a gastroenterologist and an acute care surgeon. B Show 6 more https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 7/18 6/29/23, 3:46 AM Ulcerative colitis Pathway Management of anemia, iron supplementation: As per ESPEN 2023 guidelines, initiate iron supplementation in all patients with IBD and iron deficiency anemia, to correct anemia and normalize iron stores. B Show 2 more As per ECCO 2015 guidelines, initiate iron supplementation in all patients with IBD and iron deficiency anemia. A Show 4 more Management of anemia (RBC transfusion): consider administering RBC transfusion in patients with anemia with Hgb levels < 7 g/dL, or > 7 g/dL if symptoms or particular risk factors are present, followed by subsequent IV iron supplementation. C Management of anemia (monitoring of recurrence): Monitor patients with IBD for recurrent iron deficiency every 3 months for at least a year after correction, and 6-12 months thereafter. B Consider suspecting persistent intestinal disease activity in cases of recurrent anemia, even if there is clinical remission and inflammatory parameters (such as CRP) are normal. C Management of anemia (management of recurrence): Recognize that IBD-associated iron deficiency and anemia recur frequently and fast, even after treatment with IV iron, while the recurrence of iron deficiency is lower in patients with higher post-treatment ferritin levels. B Initiate re-treatment with IV iron as soon as serum ferritin drops < 100 g/L or Hgb < 12-13 g/dL (according to gender) after successful treatment of iron deficiency anemia with IV iron. B Management of anemia (management of non-IDA anemia): exclude other possible concomitant diseases, such as infections, malignancies, and side effects of medications, in the management of non-iron deficiency anemia in patients with IBD. B Show 4 more 6. Inpatient care Clinical monitoring: Assess all patients with acute severe UC for the presence of toxic megacolon on a regular basis during the hospital admission. E Monitor treatment response in all patients with acute severe UC using stool frequency, rectal bleeding, physical examination, vital signs, and serial CRP measurements. E 7. Nonpharmacologic interventions Physical activity: encourage endurance training in all patients with IBD. Advise appropriate physical activity (mainly resistance training) in patients with IBD with decreased muscle mass and/or muscle performance. B Nutritional support (counseling): https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 8/18 6/29/23, 3:46 AM Ulcerative colitis Pathway Provide individual counseling by a dietitian as part of the multidisciplinary approach to improve nutritional therapy and avoid malnutrition and nutrition-related disorders in all patients with IBD, B as well as regarding malabsorption or maldigestion in patients with Crohn's disease. B Counsel patients with IBD with hyperoxaluria regarding fat malabsorption as they often also have fat malabsorption. B Nutritional support, general principles: As per ESPEN 2023 guidelines, obtain nutritional screening and deliver dietary management by a multidisciplinary IBD team including nurses. B Show 2 more As per AAST/WSES 2021 guidelines, initiate nutritional support (parenteral or enteral, according to gastrointestinal function and in conjunction with a dietitian/nutrition team) as soon as possible. B Nutritional support (oral nutritional supplements): offer oral nutritional supplements as the first step when medical nutrition is indicated in patients with IBD, as supportive therapy in addition to regular food. B Nutritional support (enteral nutrition): consider initiating enteral nutrition as supportive therapy if oral feeding is insufficient. C Consider initiating enteral nutrition as supportive therapy according to standard nutritional practice in patients with severe UC. C Consider preferring enteral nutrition using formulas or liquids over parenteral nutrition unless completely contraindicated. C Show 5 more Nutritional support, parenteral nutrition: As per ESPEN 2023 guidelines, avoid initiating parenteral nutrition in patients with UC unless the patient cannot be fed effectively otherwise. D Show 3 more As per AAST/WSES 2021 guidelines: Reserve TPN in nutritionally deficient patients with IBD unable to tolerate enteral nutrition and when the enteral route is contraindicated, in critically ill patients presenting with signs of shock, intestinal ischemia, high output fistula, and/or severe intestinal hemorrhage. B Initiate TPN when emergency surgery is needed for complicated IBD. A As per ACG 2019 guidelines, consider avoiding TPN for the purpose of bowel rest in acute severe UC. D Nutritional support (management of malnutrition): screen for malnutrition at the time of diagnosis and regularly thereafter in patients with IBD. B Show 2 more Nutritional support (energy requirements): ensure energy intake of 30-35 kcal/kg/day in patients with IBD, as their requirements are similar to the healthy population. Determine individual energy requirements using indirect calorimetry and an individual physical activity factor if there is a clinical suspicion of a different energy requirement in particular disease states. B Nutritional support (protein requirements): https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 9/18 6/29/23, 3:46 AM Ulcerative colitis Pathway Ensure protein intake of ~ 1 g/kg/day in adult patients with IBD in remission, as their requirements are similar to the general population. B Increase protein intake to 1.2-1.5 g/kg/day in adult patients with active IBD. B Nutritional support (micronutrient requirements): assess for micronutrient deficiencies regularly in patients with IBD, including in the remission phase, and correct specific deficits appropriately. B Nutritional support (vitamin supplements): Initiate prophylactic folic acid supplementation in selected patients with IBD, such as patients treated with sulphasalazine and methotrexate. B Do not use omega-3 fatty acids to support the maintenance of remission in patients with IBD. D Nutritional support (avoidance of dehydration): make every effort to avoid dehydration in patients with IBD. B Nutritional support (avoidance of refeeding syndrome): consider undertaking standard precautions and interventions to prevent the refeeding syndrome, particularly concerning phosphate and thiamine, in patients with IBD and nutritional deprivation extended over many days. C Probiotics: As per ESPEN 2023 guidelines: Consider offering selected probiotics or probiotics-containing preparations as an alternative to 5- aminosalicylic acid standard therapy for the treatment of mild-to-moderate active UC, if 5-aminosalicylic acid is not tolerated. C Do not offer prebiotics routinely for the treatment of active UC or maintenance of remission. D As per ACG 2019 guidelines, insufficient evidence to recommend complementary therapies, such as probiotics and curcumin, in patients with UC. I 8. Therapeutic procedures Fecal microbiota transplantation: As per ESPEN 2023 guidelines, insufficient evidence to recommend for or against fecal microbiota transplantation in patients with IBD. I As per ACG 2019 guidelines, insufficient evidence to recommend microbiota transplantation for the management of UC. This intervention requires more study and clarification of treatment before use as a therapy for UC. I Landmark trials: Fecal transplant for ulcerative colitis In patients with mild to moderately active ulcerative colitis, pooled donor fecal transplant was superior to autologous fecal transplant with respect to a steroid-free remission at 8 weeks. https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 10/18 6/29/23, 3:46 AM Ulcerative colitis Pathway Costello SP et al. JAMA. 2019 Jan 15. 9. Perioperative care Preoperative counseling: counsel patients with UC undergoing proctectomy regarding possible effects on fertility, pregnancy, sexual function, and urinary function. B Perioperative nutrition: As per ESPEN 2023 guidelines, assess nutritional status before planned surgery. Administer dietetic interventions including nutritional therapy in patients with malnutrition or at nutritional risk. B Show 10 more As per WSES 2021 guidelines, initiate preoperative nutritional support in severely undernourished patients. A Postoperative thromboprophylaxis: consider administering extended postoperative VTE prophylaxis in patients with UC exposed to tofacitinib. C 10. Surgical interventions Indications for elective surgery: As per ACG 2019 guidelines, consider elective proctocolectomy in patients with UC failing maximal medical management. E Show 3 more As per ASCRS 2014 guidelines, perform surgical intervention in patients with chronic UC when medical therapy is ineffective. B Show 3 more Indications for urgent surgery, acute severe UC: As per AAST/WSES 2021 guidelines, consider initiating second-line therapy or performing surgery in patients with acute severe UC, if the patient's condition does not improve or deteriorates within 48-72 hours from initiation of medical therapy, discussed by the emergency surgeon and the gastroenterologist. C Show 3 more As per ACG 2019 guidelines: Obtain a surgical consultation in patients with acute severe UC failing to adequately respond to medical therapy by 3-5 days or with suspected toxicity. E Perform surgical intervention in patients with acute severe UC not responding to medical therapy. E As per ASCRS 2014 guidelines: Consider either a second-line agent or surgery in patients whose condition worsens on medical therapy or who do not make significant improvement after a period of 48 to 96 hours of appropriate medical therapy. B Perform total or subtotal abdominal colectomy with end ileostomy as the procedure of choice for emergency surgery in patients with UC. B https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 11/18 6/29/23, 3:46 AM Ulcerative colitis Pathway Indications for urgent surgery, toxic megacolon: As per AAST/WSES 2021 guidelines: Do not delay surgery in critically ill patients presenting with toxic megacolon. D Perform surgery in patients presenting with toxic megacolon complicated by perforation, massive bleeding, clinical deterioration and signs of shock, A showing no clinical improvement and biological signs of deterioration after 24-48 hours of medical treatment. B As per ACG 2019 guidelines, perform surgical intervention in patients with toxic megacolon. E Indications for urgent surgery, uncontrolled bleeding: As per AAST/WSES 2021 guidelines, consider evaluating hemodynamically stable patients with IBD presenting with a gastrointestinal bleeding at first with a sigmoidoscopy and an EGD, as preoperative localization of the bleeding site, with the aim of excluding an upper gastrointestinal or an anorectal bleeding may allow better planning the surgical strategy. C Show 3 more As per ACG 2019 guidelines, perform surgical intervention in patients with severe refractory hemorrhage. E Indications for urgent surgery, perforation: As per AAST/WSES 2021 guidelines, perform surgical exploration in the presence of radiological signs of pneumoperitoneum and free fluid within the peritoneal cavity in acutely unwell patients presenting with acute severe UC. B As per ACG 2019 guidelines, perform surgical intervention in patients with colonic perforation. E As per ASCRS 2014 guidelines, perform urgent surgical intervention in patients with clinical evidence of actual or impending perforation. B Indications for urgent surgery (intestinal obstruction): Perform surgery in patients presenting with small bowel obstruction because of fibrotic or medically-resistant stenosis. B Assess any colorectal stricture with endoscopic biopsies to ensure the absence of malignancy. B Surgical approach: perform open surgery in hemodynamically unstable patient with free perforation and generalized peritonitis or toxic megacolon. B Show 2 more Surgical technique: perform total proctocolectomy with ileostomy as an acceptable surgical option in patients with UC. B Show 7 more 11. Specific circumstances Pregnant patients: Monitor iron status and folate levels regularly in pregnant patients with IBD and supplement iron and folic acid in case of deficiencies. B https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 12/18 6/29/23, 3:46 AM Ulcerative colitis Pathway Monitor nutritional status regularly in patients with IBD when breastfeeding and supplement in case of deficiencies. B Patients with obesity: as per ESPEN 2023 guidelines, advise weight loss in patients with IBD and obesity only in phases of stable remission and then according to current obesity guidelines. B Patients with pouchitis, antibiotics: As per ESPEN 2023 guidelines: Consider administering ciprofloxacin (first-line choice) or metronidazole as initial therapy in patients with acute pouchitis. C Insufficient evidence to recommend an antibiotic regimen for the prevention or management of chronic resistant pouchitis. I As per ASCRS 2014 guidelines, administer antibiotics in patients developing pouchitis after ileal pouch-anal anastomosis. B As per ACG 2010 guidelines, administer a short course of antibiotics (metronidazole 400 mg TID or 20 mg/kg daily or ciprofloxacin 500 mg BID) in patients developing typical symptoms and signs of pouchitis after ileal pouch-anal anastomosis. A Patients with pouchitis, probiotics: As per ESPEN 2023 guidelines, consider offering multistrain probiotics to prevent pouchitis. C Insufficient evidence regarding prebiotics for pouchitis. C As per AGA 2020 guidelines, consider offeirng the 8-strain combination of Lactobacillus paracasei subspecies paracasei, Lactobacillus plantarum, Lactobacillus acidophilus, Lactobacillus delbrueckii subspecies bulgaricus, Bifidobacterium longum subspecies longum, Bifidobacterium breve, Bifidobacterium longum subspecies infantis, and S. salivarius subspecies thermophilus in adult and pediatric patients with pouchitis. C Patients with ostomy: Monitor fluid output and urine sodium and adapt fluid input accordingly (decrease hypotonic fluids, increase saline solutions, limit hypertonic fluids), taking into account food intolerances that may enhance fluid output, in patients with IBD with severe diarrhea or a high output jejunostomy or ileostomy. B Consider administering parenteral infusions (fluid and electrolytes) in patients with ongoing high-output stomas. C Patients with Clostridioides difficile infection, antibiotic therapy: As per ACG 2021 guidelines, consider administering oral vancomycin (125 mg QID for a minimum of 14 days) in patients with IBD and C. difficile infection. B As per AGA 2017 guidelines, consider administering vancomycin rather than metronidazole for the treatment of C. difficile infection in patients with IBD. C Show 2 more Patients with Clostridioides difficile infection, withholding immunosuppressive therapy: As per ACG 2021 guidelines, do not hold immunosuppressive IBD therapy during anti-C. difficile infection treatment in the setting of disease flare, and consider escalating therapy if there is no symptomatic improvement with treatment of C. difficile infection. D https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 13/18 6/29/23, 3:46 AM Ulcerative colitis Pathway As per AGA 2017 guidelines, consider postponing the escalation of corticosteroids and other immunosuppression agents during acute C. difficile infection until therapy for C. difficile infection has been initiated. Decide on withholding or continuing immunosuppression in patients with IBD with C. difficile infection on an individual basis. C Patients with Clostridioides difficile infection, fecal microbiota transplantation: As per ACG 2021 guidelines, consider performing fecal microbiota transplantation in patients with IBD and recurrent C. difficile infection. B As per HIS/BSG 2018 guidelines: Offer fecal microbiota transplantation in patients with IBD and recurrent C. difficile infection. Counsel patients about a small but recognized risk of exacerbating IBD. B Do not offer fecal microbiota transplantation for the treatment of IBD. Insufficient evidence to recommend fecal microbiota transplantation for any other gastrointestinal or non- gastrointestinal disease apart from C. difficile infection. D As per AGA 2017 guidelines, offer a referral for fecal microbiota transplantation in patients with IBD and recurrent C. difficile infection. B 12. Preventative measures Routine immunizations: provide annual vaccination against influenza in all adult patients with IBD. Administer the non-live trivalent inactivated influenza vaccine, and not the live inhaled influenza vaccine, in patients on immunosuppressive therapies and their household contacts. B Show 7 more Healthy diet: advise following the principles of healthy dietary patterns and avoidance of individual nutritional triggers. Adjust the diet accordingly if particular clinical problems are still present during the remission phase. B Show 2 more Breastfeeding: advise breastfeeding as it is the optimal food for infants and reduces the risk of IBD. B 13. Follow-up and surveillance Follow-up: As per AGA 2023 guidelines, consider using a monitoring strategy combining biomarkers and symptoms in patients with UC in symptomatic remission. C Show 7 more As per ACG 2019 guidelines: Schedule routine follow-up visits are recommended to monitor for relapse and address health maintenance needs. E Screen patients with UC for coexistent anxiety and depressive disorders, and provided resources to address these conditions if they are identified. E Colorectal cancer surveillance: https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 14/18 6/29/23, 3:46 AM Ulcerative colitis Pathway As per ACG 2019 guidelines, consider obtaining colonoscopic screening and surveillance to identify neoplasia in patients with UC of any extent beyond the rectum. C Show 11 more As per ASCRS 2014 guidelines, obtain endoscopic surveillance in patients with long- standing UC. B Show 3 more Cervical cancer surveillance: obtain annual cervical cancer screening in female patients with IBD on immunosuppressive therapy. B Skin cancer surveillance: Obtain screening for melanoma in patients with IBD independent of the use of biologic therapy. B Obtain screening for non-melanoma squamous cell cancer in patients with IBD receiving immunomodulators (6-mercaptopurine or azathioprine), particularly > 50 years of age. B Clinical findings Patient demographics Symptoms White race Abdominal cramps Abdominal pain Past medical history Chronic diarrhea Defecation urgency Age < 30 Fatigue Autoimmune disorders Fever Diarrhea, often with blood or pus Inability to defecate despite urgency IBD Poorly localized abdominal pain Vital signs Rectal pain Weight loss Family history Rectal exam Ulcerative colitis Rectal blood Ocular exam Hematological findings Scleritis Anemia Lab findings blood eosinophils Inflammatory diarrhea Serological findings p-ANCA Studies https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 15/18 6/29/23, 3:46 AM Ulcerative colitis Pathway 2023 EARNEST In adult patients who developed chronic pouchitis after undergoing ileal pouch-anal anastomosis for ulcerative colitis, vedolizumab was superior to placebo with respect to modified Pouchitis Disease Activity Index-defined remission at week 14. Simon Travis et al. N Engl J Med. 2023 Mar 30. 2019 Fecal transplant for ulcerative colitis In patients with mild to moderately active ulcerative colitis, pooled donor fecal transplant was superior to autologous fecal transplant with respect to a steroid-free remission at 8 weeks. Costello SP et al. JAMA. 2019 Jan 15. References 1. Stephan C Bischoff, Palle Bager, Johanna Escher et al. ESPEN guideline on Clinical Nutrition in inflammatory bowel disease. Clin Nutr. 2023 Jan 13;42 3 352 379. Open 2. Rubin DT, Ananthakrishnan AN, Siegel CA et al. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol. 2019 Mar;114 3 384 413. Open 3. Belinda De Simone, Justin Davies, Elie Chouillard et al. WSES AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg. 2021; 16 23. Open 4. Stephan C Bischoff, Johann Ockenga, Ahad Eshraghian et al. Practical guideline on obesity care in patients with gastrointestinal and liver diseases Joint ESPEN/UEG guideline. Clin Nutr. 2023 Apr 10;42 6 987 1024. Open 5. Ross H, Steele SR, Varma M et al. Practice parameters for the surgical treatment of ulcerative colitis. Dis Colon Rectum. 2014 Jan;57 1 5 22. Open 6. Sahil Khanna, Andrea Shin, Ciar n P Kelly. Management of Clostridium difficile Infection in Inflammatory Bowel Disease: Expert Review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017 Feb;15 2 166 174. Open 7. Colleen R Kelly, Monika Fischer, Jessica R Allegretti et al. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021 Jun 1;116 6 1124 1147. Open 8. Francis A Farraye, Gil Y Melmed, Gary R Lichtenstein et al. ACG Clinical Guideline: Preventive Care in Inflammatory Bowel Disease. Am J Gastroenterol. 2017 Feb;112 2 241 258. Open 9. Mullish BH, Quraishi MN, Segal JP et al. The use of faecal microbiota transplant as treatment for recurrent or refractory Clostridium difficile infection and other potential indications: joint British Society of Gastroenterology BSG and Healthcare Infection Society HIS guidelines. Gut. 2018 Nov;67 11 1920 1941. Open 10. Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2010 Mar;105 3 501 23. Open 11. Grace L Su, Cynthia W Ko, Premysl Bercik et al. AGA Clinical Practice Guidelines on the Role of Probiotics in the Management of Gastrointestinal Disorders. Gastroenterology. 2020 Aug;159 2 697 705. Open https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 16/18 6/29/23, 3:46 AM Ulcerative colitis Pathway 12. Stefan D Holubar, Amy L Lightner, Vitaliy Poylin et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis. Dis Colon Rectum. 2021 Jul 1;64 7 783 804. Open 13. Joseph D Feuerstein, Kim L Isaacs, Yecheskel Schneider et al. AGA Clinical Practice Guidelines on the Management of Moderate to Severe Ulcerative Colitis. Gastroenterology. 2020 Apr;158 5 1450 1461. Open 14. Axel U Dignass, Christoph Gasche, Dominik Bettenworth et al. European consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases. J Crohns Colitis. 2015 Mar;9 3 211 22. Open 15. Tim Raine, Stefanos Bonovas, Johan Burisch et al. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment. J Crohns Colitis. 2022 Jan 28;16 1 2 17. Open 16. Expert Panel on Gastrointestinal Imaging: Angela D. Levy, MD, Peter S. Liu et al. ACR Appropriateness Criteria Anorectal Disease. ACR. 2021. Open 17. Siddharth Singh, Ashwin N Ananthakrishnan, Nghia H Nguyen et al. AGA Clinical Practice Guideline on the Role of Biomarkers for the Management of Ulcerative Colitis. Gastroenterology. 2023 Mar;164 3 344 372. Open 18. Conrad K, Roggenbuck D, Laass MW. Diagnosis and classification of ulcerative colitis. Autoimmun Rev. 2014 Apr-May;13 4 5 463 6. Open 19. Danese S, Fiocchi C. Ulcerative colitis. N Engl J Med. 2011 Nov 3;365 18 1713 25. Open 20. Ng SC, Shi HY, Hamidi N et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet. 2018 Dec 23;390 10114 2769 2778. Open 21. Gajendran M, Loganathan P, Jimenez G et al. A comprehensive review and update on ulcerative colitis. Dis Mon. 2019 Mar 2. pii: S0011 5029 19 30031 8. Open 22. Winther KV, Jess T, Langholz E et al. Survival and cause-specific mortality in ulcerative colitis: follow-up of a population-based cohort in Copenhagen County. Gastroenterology. 2003 Dec;125 6 1576 82. Open 23. Kathryn A. Myers, MD, EdM et al. Does This Patient Have Clubbing?. JAMA. 2001;286 3 341 347. Open 24. Feuerstein JD, Nguyen GC, Kupfer SS et al. American Gastroenterological Association Institute Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease. Gastroenterology. 2017 Sep;153 3 827 834. Open 25. Costello SP, Hughes PA, Waters O et al. Effect of Fecal Microbiota Transplantation on 8 Week Remission in Patients With Ulcerative Colitis: A Randomized Clinical Trial. JAMA. 2019 Jan 15;321 2 156 164. Open 26. James D. Lewis, M.D., M.S.C.E. et al. Use of the Non-invasive Components of the Mayo Score to Assess Clinical Response in Ulcerative Colitis. Inflamm Bowel Dis. 2008 Dec; 14 12 1660 1666. Open 27. Baldeep Singh Pabla, MD, MSCI and David Allen Schwartz et al. Assessing Severity of Disease in Patients with Ulcerative Colitis. Gastroenterol Clin North Am. 2020 Dec; 49 4 671 688. Open 28. Truelove SC, Witts LJ. Cortisone in ulcerative colitis; final report on a therapeutic trial. Br Med J. 1955 Oct 29;2 4947 1041 8. Open https://web.pathway.md/diseases/recPfEbvwZ5o0OFe2 17/18 6/29/23, 3:46 AM Ulcerative colitis Pathway