Acute Severe UC, modified Truelove-Witts

Does this patient meet the modified Truelove and Witts criteria for acute severe ulcerative colitis right now? Six or more bloody stools a day plus any one systemic-toxicity sign.

Adults with ulcerative colitis presenting with an acute flare. One question, one verdict. This is the admission decision, not a phenotype. It does not grade mild versus moderate and it does not classify extent; for that use the companion Montreal Classification tool, which uses different thresholds. A 'not met' result is the absence of a positive trigger, never reassurance. Not for paediatric patients. Use PUCAI. Do not enter protected health information.

Caveats

This tool does not grade mild versus moderate

Truelove-Witts answers one question: acute severe or not. It has no mild / moderate band. The Montreal S0-S3 scale quoted here does, and lives in the companion Montreal Classification tool. Note the thresholds are NOT the same: Montreal S3 uses temperature >37.5 C and ESR >30 mm/h, modified Truelove-Witts uses >37.8 C and CRP >30 mg/L. A patient can be S3 without meeting Truelove-Witts, and the reverse -- which is exactly why the two are separate tools rather than one form.

“For UC, the extent of disease (E) is denoted by E1 for ulcerative proctitis, E2 for left-sided disease, and E3 for extensive disease (extending beyond the splenic flexure). Severity (S) is categorized as S0 for clinical remission, S1 for mild disease (≤4 bloody stools daily, lack of fever, pulse < 90 bpm, hemoglobin > 105 g/L, ESR < 30 mm/h) S2 for moderate disease (>4-5 stools daily but with minimal signs of systemic toxicity), and S3 for severe disease (≥ 6 bloody stools daily, pulse > 90 bpm, temperatures > 37.5 °C, hemoglobin < 105 g/L, ESR > 30 mm/h).”

Exploring Dual-Targeted Therapy in the Management of Moderate to Severe Inflammatory Bowel Disease: A Retrospective Study. · 2025 · PMID 39877297

Criteria are a floor, not a ceiling

BSG's statement is a recommendation to ADMIT patients meeting the criteria; it is not a rule that patients failing them are safe to send home. A patient with severe pain, marked systemic upset, or a clinician's concern warrants inpatient assessment regardless of what this tool returns. Treat a 'not met' result as the absence of a positive trigger, never as reassurance.

“statement 15. We recommend that adult patients with acute severe ulcerative colitis (ASUC) (defined by the modified Truelove and Witts criteria as >6 bloody stools per day and systemic toxicity with at least one of: temperature >37.8°C, pulse >90 bpm, haemoglobin <105 g/L or C-reactive protein >30 mg/L) or adolescents with a Paediatric Ulcerative Colitis Activity Index (PUCAI) score of 65 or more should be admitted to hospital for assessment and intensive management (GRADE: strong recommendation, low-quality evidence. Agreement: 100%).”

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. · 2019 · PMID 31562236