Acute severe ulcerative colitis without systemic toxicity: A retrospective multicenter cohort study suggesting refining the definition of acute severe ulcerative colitis

Abstract Background Acute severe ulcerative colitis (ASUC) is defined by the Truelove and Witts (TW) criteria. However, contemporary practice has shifted toward earlier admission and treatment escalation in advanced therapy–experienced patients, resulting in a growing subgroup hospitalized for ASUC who do not fulfill TW (non-TW ASUC). This population remains poorly characterized. Methods Retrospective cohort study of all patients hospitalized for ASUC and treated with intravenous corticosteroids at a Danish tertiary center until 2023. The primary outcome of 1-year colectomy was assessed in an independent validation cohort. Results Of 109 included patients, 80 (73%) fulfilled TW criteria and 29 (27%) did not. Non-TW ASUC patients were less often female (28% vs 63%; P .01), were less frequently steroid-naïve (21% vs 48%; P .05), and presented with lower systemic inflammation (C-reactive protein median 7 mg/L vs 34 mg/L; P .001; hemoglobin 13.7 g/dL vs 12.2 g/dL; P .001; albumin 41 g/L vs 38 g/L; P .001). Colectomy-free survival and colectomy rates at 1, 3, and 12 months were comparable between non-TW and TW ASUC (14% vs 10%, 21% vs 16%, and 29% vs 19%, respectively; P .05). Results were similar in the validation cohort (n = 43). Medical rescue therapy use, tumor necrosis factor inhibitor exposure, and readmission rates through 1 year did not differ significantly. Prognostic indices (Ho, Lindgren, Travis) similarly identified high-risk patients across both groups. Non-TW patients had shorter hospital stay (mean 6.5 days vs 8.6 days; P .01). Conclusion Non-TW ASUC shows a disease course and outcomes comparable to TW ASUC, underscoring an equally severe and comparable condition. These findings emphasize a need to broaden ASUC definitions to reflect contemporary practice.