Abstract Background Acute severe ulcerative colitis (ASUC) is traditionally defined by Truelove Witts (TW) criteria.1 However, contemporary practice has evolved toward earlier admission and more proactive treatment escalation during severe flares—often before systemic toxicity develops. As a result, an increasing proportion receive ASUC-level care despite not fulfilling TW criteria.2 This population of ‘non-TW ASUC’ remains poorly characterised. Methods Retrospective cohort study of all patients hospitalised for ASUC and treated with iv corticosteroids in a Danish tertiary centre until 2023. The primary outcome of 1-year colectomy was also assessed in a ‘confirmatory’ cohort from another tertiary Danish IBD centre. Results The study population comprised 109 ASUC patients of which 80 (73%) complied with TW criteria and 29 (27%) did not. The non-TW group contained less female (28% vs. 63%, p 0.01), less steroid-naïve (21% vs. 48%, p 0.05), and, as expected, presented with less systemic signs of inflammation (CRP median 7 mg/L vs. 34, p 0.001; haemoglobin 13.7 g/dL vs. 12.2, p 0.001; albumin 41 g/L vs. 38, p 0.001). Colectomy rates at 1, 3, and 12 months were similar between non-TW and TW ASUC (14% vs. 10%; 21% vs. 16%; 29% vs. 19%; all p 0.05), and without differences in colectomy-free survival. The confirmatory cohort comprised 25 (58%) ASUC patients complying with TW and 18 (42%) non-TW. Colectomy rates were also similar in this cohort (1 month: 0% vs. 0 %; 3 months: 12% vs. 28%; 12 months: 12% vs. 28%; all p 0.05). When combining the cohorts, colectomy rates remained similar between TW (n = 105) and non-TW ASUC (n = 47), i.e., 1 month: 8% vs. 9%, p = 0.77; 3 months: 15% vs. 23%, p = 0.26; 12 months: 17% vs. 28%, p = 0.19) (Figure). Secondary outcomes assessed at 1 year in the primary cohort were similar between TW and non-TW ASUC (medical rescue therapy 43% vs. 31%, p = 0.38; TNF-inhibitor initiation 79% vs. 69%, p = 0.32; readmission 39% vs. 33%, p = 0.80). Similar proportions of non-TW and TW ASUC patients had high risk of steroid failure at day 3 according to prognostic indices (i.e., Ho, Lindgren, Travis), and outcomes according to stratification for severity by these indices were similar. Non-TW ASUC patients had shorter hospital stay (mean 6.5 days vs. 8.6, p 0.01). A single serious adverse event (death after colectomy) was observed occurring in the TW ASUC group. Conclusion Non-TW ASUC patients demonstrated similar disease course and treatment outcomes to those meeting TW criteria. Thus, non-TW ASUC reflect clinically significant disease warranting ASUC-level care, though further research is needed to optimize risk stratification and inform potential refinements of the ASUC definition in contemporary practice. References: 1. Truelove SC, Witts LJ. Cortisone in ulcerative colitis: final report on a therapeutic trial. Br Med J. 1955;2(4947):1041-1048. 2. Honap S, et al. Acute severe ulcerative colitis trials: the past, the present and the future. Gut. 2024;73(10):1763-1773. Conflict of interest: Mr. Ørtoft, Frederik: No conflict of interest Steenholdt, Casper: Lectures for Takeda, MSD and Janssen-Cilag research grant from Takeda. Nissen, Mathilde Jepsen: No conflict of interest Kjeldsen, Jens: No conflict of interest Ainsworth, Mark Andrew: Other: None
Ørtoft et al. (2026) studied this question.