Classifies UC as mild, moderate, or severe. Acute Severe UC (ASUC) = ≥ 6 bloody stools/day + at least 1 systemic feature. Requires immediate hospitalisation and IV corticosteroids. Oxford 1955.
Bloody Stools per Day
Pulse Rate
Temperature
Haemoglobin
ESR
CRP (BSG 2019 addition)
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Classifying acute ulcerative colitis as mild, moderate, or severe at initial presentation or flare.
Identifying acute severe UC (ASUC) to trigger urgent hospitalisation and IV corticosteroid therapy.
Simple bedside triage tool requiring only clinical examination and basic blood tests.
ECCO, BSG, and ACG guideline standard for severity classification and admission criteria.
Why This Matters
Acute severe UC (≥ 6 bloody stools/day + any systemic feature) carries a colectomy rate of 20–30% per admission. Immediate IV hydrocortisone and specialist GI/surgical co-management is mandatory.
Section 2
Formula & Logic
Severity Classification
Feature
Mild
Severe
Bloody stools per day
< 4
≥ 6
Pulse
Normal
> 90 bpm
Temperature
Afebrile
> 37.8°C on ≥ 2 of 4 days
Haemoglobin
Normal
< 10.5 g/dL
ESR
Normal
> 30 mm/hr
CRP
Normal
> 30 mg/L (added by BSG 2019)
Moderate Disease
Moderate UC = features between mild and severe. Defined as ≥ 4 bloody stools/day with minimal systemic disturbance — no single threshold defines moderate; it is diagnosed by exclusion of mild and severe.
Oxford ASUC Criteria
Acute Severe UC (ASUC) = ≥ 6 bloody stools/day PLUS at least one of: pulse > 90, temperature > 37.8°C, Hb < 10.5 g/dL, ESR > 30 mm/hr.
Section 3
Pearls/Pitfalls
Day-3 Response Assessment (Travis Criteria)
After 72h of IV hydrocortisone: assess Day-3 stool frequency and CRP.
> 8 stools/day on Day 3, OR CRP > 45 mg/L + 3–8 stools/day = 85% probability of requiring colectomy during that admission.
In this scenario: escalate to rescue therapy (infliximab or ciclosporin) or proceed to colectomy.
Involve colorectal surgical team from Day 1 — do not wait until medical rescue therapy fails.
Common Errors
Underestimating severity — CRP > 30 should always prompt reassessment.
Failing to exclude infective colitis (C. diff, CMV) before and during steroid therapy.
Delayed surgical referral — surgery after multiple failed rescue agents carries higher morbidity.
Section 4
Next Steps
Clinical Actions
01
Mild UC: Oral 5-ASA (mesalazine ≥ 2.4g/day ± topical); outpatient management with close follow-up.
02
Moderate UC: Oral prednisolone 40mg/day; review at 2 weeks; escalate if no response.
03
Severe UC (ASUC): Admit; IV hydrocortisone 400mg/day (100mg QDS); stool cultures including C. diff; surgical team referral from Day 1; daily bloods; thromboprophylaxis; nutritional support.
04
Day-3 review: Apply Travis criteria. If poor response → rescue therapy (infliximab or ciclosporin) after excluding contraindications.
Section 5
Evidence Appraisal
Primary Reference
Cortisone in ulcerative colitis: final report on a therapeutic trial
Truelove SC et al. • British Medical Journal. 1955;2(4947): 1041–1048
Predicting outcome in severe ulcerative colitis
Travis SP et al. • Gut. 1996;38(6): 905–910
Section 6
Literature
The First RCT in IBD
Published in 1955 by Sidney Truelove and Leonard Witts at the Radcliffe Infirmary, Oxford, the Truelove & Witts criteria emerged from the first randomised controlled trial of cortisone in ulcerative colitis. The severity classification was a secondary output of this landmark trial, defining objective thresholds to stratify disease and guide treatment escalation.
Durability
Remarkably, after 70 years, the core Oxford criteria remain the most widely cited classification system for UC severity in international guidelines (ECCO, BSG, ACG). The BSG 2019 update added CRP > 30 mg/L as an additional criterion for severe disease, reflecting improved biochemical monitoring. The Travis Day-3 criteria (1996) extended the framework into a practical rescue therapy decision tool.
