Medical Therapy in Chronic Refractory Ulcerative Colitis: When Enough Is Enough

Despite significant improvements in the management of ulcerative colitis (UC) in parallel with the evolution of therapeutic targets and novel biologics and small molecules, a subset of medically refractory patients still requires colectomy. Recent population-based studies demonstrate a trend toward a decrease in the rates of surgery for UC patients in the biological era, although the potential of disease modification with these agents is still debated. As the concept of irreversible bowel damage is underexplored in UC, refractory patients can be exposed to multiple treatments losing optimal timing for surgery and further developing complications such as dysplasia/cancer, dysmotility, microcolon, and other functional abnormalities. This review aims to discuss the concept of disease progression in UC, explore the limitations of medical treatment in refractory UC patients, and propose the application of a three-step algorithm that allows timely indication for surgery in clinical practice.

Automated summary

Despite improvements in the management of ulcerative colitis, there is still a subset of medically refractory patients who require surgery. Recent studies show a decrease in surgery rates for ulcerative colitis patients in the biological era, but the potential for disease modification with these treatments is still debated. Medically refractory patients may receive multiple treatments, resulting in missed opportunities for surgery and the development of complications.