MBBS OSCE · Gastroenterology
OSCE — assessment of acute severe ulcerative colitis
An 8-minute OSCE station assessing the candidate's structured assessment, severity grading (Truelove-Witts), toxic-megacolon recognition and immediate management of a patient with acute severe ulcerative colitis. Marks for stopping opiates, IV hydrocortisone with dose, VTE prophylaxis and early surgical review.
On this page
Study tools
Exam tags
Brief (to candidate)
A 32-year-old woman with known ulcerative colitis is referred with 10 bloody stools per day, fever and abdominal distension. She is pale, heart rate 110/min, BP 102/64, temperature 38.3 degrees C, with a tender, distended abdomen and absent bowel sounds in the right iliac fossa. Abdominal X-ray shows a transverse colon of 7 cm with loss of haustra. You have 8 minutes to assess her, grade severity, recognise complications and outline immediate management.
Candidate instructions
- Take a focused, structured history and examine using an ABCDE approach.
- Grade severity using an appropriate score, and identify the complication.
- Outline the immediate medical management, including investigations and drug therapy with doses, routes and timing.
- State your surgical triggers and escalation plan, and the safety-net / disposition advice.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| ABCDE / resuscitation | Airway; oxygen if hypoxic; IV access; fluids for tachycardia/hypovolaemia; group and save |
| Severity — Truelove-Witts | Reproduces components (>=6 bloody stools/day plus >=1 of HR>90, temp>37.8, Hb less than 10.5, ESR>30); states this patient = severe |
| Complication recognised | Identifies toxic megacolon (dilated colon, distension, absent bowel sounds) and the need for surgical review |
| Toxic-megacolon bundle | Nil-by-mouth + NG tube; IV ciprofloxacin + metronidazole; stop opiates/anticholinergics; daily AXR |
| Steroid + supportive | IV hydrocortisone 100 mg QDS (or 400 mg/day); VTE prophylaxis; correct anaemia/electrolytes; stool C. difficile |
| Escalation / surgery | Day-3 reassessment; infliximab or IV ciclosporin rescue if refractory; colectomy for perforation/peritonitis/deterioration |
| Communication & safety-net | Joint medical-surgical care; counsels on possible colectomy (curative in UC); plans cancer surveillance at 8-year mark |
Model key actions
- IV hydrocortisone 100 mg four times daily as induction; nil-by-mouth, NG tube.[1]
- Stop all opiates and anticholinergics (loperamide precipitates/worsens megacolon); IV ciprofloxacin plus metronidazole; daily abdominal X-ray.[1][7]
- Exclude C. difficile on stool; VTE prophylaxis; urgent surgical review.
- Escalation: infliximab 5 mg/kg or IV ciclosporin if steroid-refractory; colectomy for perforation, peritonitis or progressive dilatation.[7]
Common errors
- Giving loperamide/an opiate (worsens toxic megacolon).
- Not grading severity or not recognising toxic megacolon as a complication.
- Using 5-ASA or azathioprine as acute therapy (too slow).
- Forgetting VTE prophylaxis and C. difficile exclusion.
- Delaying surgical review until after perforation.
References2ShowHide
- [1]Rubin DT, et al. ACG Clinical Guideline: Ulcerative Colitis in Adults. Am J Gastroenterol, 2019.PMID 30840605
- [7]Magro F, et al. Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Journal of Crohn's and Colitis, 2017.PMID 28158501