A four-round modified Delphi consensus panel (REFINED-ASUC Working Group) of European, North American, and Asia-Pacific gastroenterologists evaluated new diagnostic criteria for acute severe ulcerative colitis (ASUC) applicable to patients already receiving corticosteroids or advanced therapies — limitations not addressed by the original 1955 Truelove and Witts criteria.
Consensus (≥70% agreement) was reached that ASUC diagnosis in patients on advanced therapy or corticosteroids requires all 3 major criteria (CRP ≥2× ULN, ≥6 bowel movements/24h, ≥50% bowel movements with visible blood/24h) plus ≥2 of 6 minor criteria (low albumin, elevated heart rate, nocturnal stools, low hemoglobin, elevated temperature, or elevated leukocyte count); patients on high-dose corticosteroids use lower thresholds (CRP ≥1× ULN, ≥33% bloody stools). Endoscopy to confirm diagnosis and exclude CMV, plus radiology to rule out toxic megacolon, were also endorsed.
- Consensus was not achieved for diagnostic criteria in treatment-naive patients, leaving a gap for that common scenario. - Criteria are expert-opinion based and have not yet been validated in prospective studies. - Delphi methodology inherently reflects expert opinion rather than empirical patient-level data.
When a patient on advanced therapy or steroids presents with ≥6 stools/day (≥50% bloody) and CRP ≥2× ULN, plus ≥2 minor clinical/lab features, consider ASUC and proceed with confirmatory endoscopy and CMV exclusion. For patients already on high-dose corticosteroids, apply lower thresholds (CRP ≥1× ULN; ≥33% bloody stools) to avoid missing severity.
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