Question 1

What is the role of CRP in the Truelove and Witts criteria?

Accepted Answer

The original criteria predated routine CRP testing and use ESR instead. In contemporary practice, CRP is often used as a substitute, though ESR remains in the traditional criteria. A CRP > 30 mg/L is commonly considered an alternative to ESR in the severe classification.

Question 2

Can I use these criteria in a patient on immunosuppressants?

Accepted Answer

Yes — the criteria remain valid regardless of background therapy. However, immunosuppressed patients may have a blunted inflammatory response, so the absence of fever or elevated ESR/CRP does not rule out severe colitis. Lower the threshold for endoscopy and imaging in this population.

Question 3

What if the patient has haemorrhoids contributing to bloody stools?

Accepted Answer

The Truelove and Witts criteria focus on UC disease activity. If haemorrhoids are present, it can be difficult to attribute bleeding solely to UC. However, in a patient with confirmed UC, the pattern of bloody diarrhoea with urgency is characteristic of active disease. Endoscopic assessment can help clarify the source.

Question 4

How quickly should I escalate to colectomy if the patient fails steroids?

Accepted Answer

ECCO guidelines recommend assessing response to IV corticosteroids by day 3 using the Oxford criteria (stool frequency > 8/day or CRP > 45 mg/L). If these are met, the risk of needing colectomy during that admission is approximately 85%. Early surgical consultation and consideration of infliximab or ciclosporin salvage therapy should not be delayed beyond day 3–5.