High-yield map
Key points before the detail
- 01
Montreal E1–E3 describes disease extent.
- 02
Steroids induce remission but must not maintain it.
- 03
Acute severe UC is ≥6 bloody stools/day plus systemic toxicity.
- 04
Day 3 is the key response checkpoint after IV steroids.
- 05
Emergency surgery is subtotal colectomy with end ileostomy, not immediate pouch surgery.
1. Extent matters
| Extent | Definition | Why it matters |
|---|---|---|
| E1 proctitis | Rectum only. | Topical therapy targets disease directly. |
| E2 left-sided colitis | Distal to splenic flexure. | Topical plus oral mesalazine often useful. |
| E3 extensive colitis | Proximal to splenic flexure. | Greater systemic burden and colorectal cancer risk. |
2. Clinical features
- Bloody diarrhoea, mucus, urgency, tenesmus and nocturnal stools.
- Weight loss, fever, tachycardia and anaemia suggest more extensive or severe inflammation.
- Severe continuous pain, distension or peritonism suggests toxic megacolon, perforation or another diagnosis.
- Exclude infection, especially C. difficile, before assuming every flare is inflammatory.
3. Acute severe UC
Truelove and Witts defines acute severe UC as at least six bloody stools per day plus at least one marker of systemic toxicity. It is an admission diagnosis.
| Clue | Implication |
|---|---|
| ≥6 bloody stools/day plus systemic toxicity | Admit under joint gastroenterology-colorectal care. |
| Distension, severe tenderness or radiographic dilatation | Suspect toxic megacolon. |
| Free air, peritonitis, uncontrolled haemorrhage or shock | Emergency colectomy pathway. |
4. Day 0 to day 3
- Send stool testing and baseline bloods, obtain abdominal imaging and early limited flexible sigmoidoscopy.
- Start high-dose IV corticosteroids, fluids/electrolytes and nutritional support.
- Give pharmacological VTE prophylaxis unless contraindicated.
- Stop antimotility agents and avoid opioids where possible.
- Involve the stoma team early.
5. When and how to operate
- Immediate surgery for perforation, uncontrolled haemorrhage, worsening toxic megacolon, peritonitis or shock.
- The standard acute operation is subtotal colectomy with end ileostomy and preservation of the rectal stump.
- Avoid restorative pouch construction during the acute toxic, malnourished or high-dose steroid phase.
6. Elective surgery
- Discuss stool frequency, pouchitis, fertility, pelvic function and possibility of pouch failure.
| Option | Principle |
|---|---|
| Restorative proctocolectomy with IPAA | Removes colon/rectum and creates an ileal pouch; often staged. |
| Total proctocolectomy with end ileostomy | Definitive option without pouch complications. |
| Subtotal colectomy with retained rectum | Emergency or staged first operation; retained rectum still requires symptom/dysplasia management. |
Active recall
Close the notes and answer these
Try each question from memory before revealing the answer. These public prompts are a small preview of the integrated retrieval system inside SurgAtlas.
01What do Montreal E1, E2 and E3 describe?
Extent of ulcerative colitis: proctitis, left-sided colitis and extensive colitis.
02Can corticosteroids be used for maintenance?
No. They are induction therapy only.
03How is acute severe UC defined?
At least six bloody stools per day plus at least one marker of systemic toxicity.
04What is the key reassessment time after starting IV steroids?
Around day 3.
05What is the standard emergency operation for failing acute severe UC?
Subtotal colectomy with end ileostomy and preservation of the rectal stump.
Sources & editorial basis
References & editorial basis
- SurgAtlas production source. General Surgery — Ulcerative Colitis. Public lesson curated from the corresponding production chapter.
- NICE NG130. Ulcerative colitis: management.
- BSG IBD guideline. British Society of Gastroenterology guidelines on inflammatory bowel disease in adults: 2025.
This lesson is derived from the corresponding SurgAtlas production teaching material. Where the source makes current management or guideline claims, the public lesson uses the cited contemporary guidance. It is written for education and examination preparation, not as patient-specific clinical advice.
Editorial details
Medical Doctor (MD) · MRCS Part A · Physician · Surgical Educator
SurgAtlas is an educational resource. For patient care, verify current national guidance, local antimicrobial and transfusion policies, specialty pathways and individual patient factors.
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