Dr. Elizabeth Squirell

Acute severe UC (day 1 and day 3)

Truelove and Witts on admission, Travis criteria on day 3, and rescue-therapy checks

Reviewed October 2026

For healthcare professionals. A decision aid, not a substitute for clinical judgement.

Is this acute severe UC? Truelove and Witts criteria, red flags and the admission checklist.

Stools

Count the last 24 hours.

Bowel movements in 24 hours
per day
Visible blood in the stools

Systemic signs

Any one sign is enough. Enter ESR, CRP or both.

Pulse
beats/min
Temperature
°C
Hemoglobin
g/L
ESRLeave blank if not measured.
mm/h
CRPCRP >30 mg/L is the modified criterion (used in place of ESR).
mg/L

Red flags

Tick any that are present. Unticked means not present.

Admission checklist

Tick what is done. Each item shows its source.

Day 1 · Truelove and Witts

Answer 6 more items to see the result.

  • Stools in 24 hours
  • Visible blood
  • Pulse
  • Temperature
  • Hemoglobin
  • ESR or CRP

How to use it

Use Day 1 on admission. It checks the Truelove and Witts criteria: 6 or more bloody stools a day plus at least one sign of systemic toxicity (pulse >90, temperature >37.8 °C, Hb below 105 g/L, ESR >30 mm/h). CRP >30 mg/L counts as the modern substitute for ESR (the “modified” criteria in BSG 2019). Tick the admission checklist as you go; the chart note lists what is done and what is outstanding.

Use Day 3 after 72 hours of IV steroids. Enter the stool count and CRP for that day. The Ho score and the rescue checks are optional.

Reading the result

Day 3 finding What it means What to do
>8 stools, or 3–8 stools with CRP >45 mg/L (Travis) About 85% needed colectomy on that admission Rescue therapy (infliximab or ciclosporin) or colectomy now, with the surgeon
Travis not met, but >3 stools or visible blood Response not established Rescue discussion today; reassess daily; no oral switch yet
Lindgren index (stools + 0.14 × CRP) >8 About 72% steroid failure Treat as high risk even if Travis is not met
≤3 stools, no visible blood, index not high Improving Continue IV steroids; switch to oral prednisone once sustained

Missing the Travis criteria is not the same as responding. The criteria pick out the patients most likely to need surgery; they were not designed to identify responders. In Travis’s cohort, incomplete responders on day 7 still had a 40% chance of colectomy in the following months.

Rescue therapy

  • Infliximab 5 mg/kg at weeks 0, 2 and 6. Screen for TB and HBV first. ACG 2025 and BSG 2025 suggest considering intensified dosing when albumin is low (ACG: below 25 g/L). In PREDICT-UC (138 patients), a 10 mg/kg first dose or accelerated induction was not better than standard dosing for day-7 response or colectomy at 3 months. ECCO 2026 (Rec 46) finds insufficient evidence for routine intensified dosing but allows individualised dosing. A PREDICT-UC secondary analysis suggests that patients with high early clearance may benefit from 10 mg/kg, and that a day-3 level of 57.9 µg/mL or less predicts colectomy (NPV 97%, PPV 24%) (Li Wai Suen 2026); this is exploratory. It remains a judgement call.
  • Ciclosporin 2 mg/kg/day IV (trough 150–250 ng/mL), then oral as a bridge to a thiopurine or vedolizumab. Avoid it after thiopurine failure. Low cholesterol or magnesium raises the risk of seizures; nephrotoxicity and hypertension are dose-related.
  • CONSTRUCT (270 patients) and CySIF (115 patients) found no difference between the two in colectomy rates or quality of life, and ECCO 2026 recommends either (Rec 45, high certainty). A 2025 meta-analysis that added cohort studies favoured infliximab for colectomy, at the cost of more infections, but the certainty was low (Vuyyuru 2025). Choose by local experience, prior drug failure and albumin (ACG 2025).
  • Sequential rescue (infliximab then ciclosporin, the reverse, or a JAK inhibitor as a third line): ECCO 2026 (Rec 47) allows it only in highly selected patients at experienced centres after surgery has been discussed; BSG 2025 found insufficient evidence to recommend it; the Toronto consensus advises against it. Outside such a centre, failure of one rescue drug means colectomy. No response within 7 days of rescue therapy, or any complication, means subtotal colectomy.
  • JAK inhibitors: TACOS (one RCT) showed benefit with off-label tofacitinib 10 mg three times daily added to IV steroids; the rest of the evidence is observational (Jena 2026). ACG 2025 says the data are not enough for routine use. BSG 2025 (GPS 48) says they may be considered in selected steroid-refractory patients, and its text restricts them to patients in whom conventional rescue is contraindicated or has failed. ECCO 2026 (practice point 2) suggests considering them when infliximab or ciclosporin has failed or cannot be given. This tool follows the ECCO 2026 and BSG 2025 position: not first-line rescue; a specialist decision after infliximab or ciclosporin has failed or cannot be used, with surgery discussed. Ustekinumab or vedolizumab alone are not rescue options (ECCO 2026).
  • After a response to IV steroids, plan maintenance before discharge. BSG 2025 (GPS 43) suggests a thiopurine or an advanced therapy. ECCO 2026 (practice point 1) suggests against a thiopurine or 5-ASA alone, based on the ACTIVE trial (64 patients: treatment failure at 1 year 53% with infliximab plus azathioprine vs 82% with azathioprine alone).

Pitfalls

  • Don’t wait for stool results before starting IV steroids. Treat C. difficile alongside them: oral vancomycin 125 mg four times daily for 10 days is first line, with fidaxomicin 200 mg twice daily for 10 days as the alternative. IDSA/SHEA 2021 prefers fidaxomicin, but coverage in Canada favours vancomycin (in Ontario, fidaxomicin is funded through the Exceptional Access Program only after vancomycin). Not metronidazole (ECCO 2026).
  • CMV: ask for immunohistochemistry or PCR on biopsies. H&E alone misses it. ECCO 2026 suggests antivirals for steroid-refractory CMV colitis; immunosuppression can usually continue.
  • Oral 5-ASA: don’t add it to IV steroids (ECCO 2026 Rec 44: no benefit in a randomised trial).
  • Patients already on steroids or advanced therapy may not meet Truelove and Witts despite severe disease. A 2026 Delphi consensus proposed new criteria for them (Raine 2026); they are not yet validated.
  • Colonic dilatation ≥5.5 cm predicts a worse outcome. With systemic toxicity it is toxic megacolon, which needs urgent surgery.
  • Opioids and anticholinergics can precipitate dilatation. Use acetaminophen and non-drug measures.
  • Beyond day 7 of IV steroids, further response is unlikely. Make a decision.

Guideline differences

ECCO’s 2026 UC medical treatment guideline replaces its 2022 version and now covers ASUC; it is cited above. The main differences between guidelines are on intensified infliximab, sequential rescue, JAK inhibitors and maintenance after a steroid response (see Rescue therapy). ACG 2025 and AGA 2026 give methylprednisolone 60 mg/day; BSG 2025 gives 30 mg every 12 hours or hydrocortisone 100 mg four times daily: the same dose. The Travis criteria were derived before biologics; a 2025 review notes they may perform less well in patients already on advanced therapy or with a blunted CRP. Use them with clinical judgement and local protocols. For the steroid taper after discharge, see the steroid taper builder; for screening before rescue therapy, see advanced therapy screening.

Try “pregnancy”, “Mayo”, “calprotectin” or “VARSITY”.