A survey on the practices and patterns in the management of acute severe ulcerative colitis in India

1. Survey Design and Development

We designed a structured, web-based survey using Google Forms (Google LLC, Mountain View, CA, USA) to evaluate current practices and patterns in the management of ASUC among gastroenterologists in India. The questionnaire was developed after a thorough review of existing literature and clinical guidelines on ASUC, and was refined through iterative feedback from a panel of experts with experience in IBD. The final version of the survey consisted of 5 thematic sections (Supplementary Material 1). Ethical approval was not required for this study, as it reports observations from a web-based survey. Participants were informed via email about the survey duration, the purpose of the study, and the identity of the investigator. Participation was voluntary, and informed consent was implied through survey completion.

2. Survey Distribution and Data Collection

Participation in the survey was entirely voluntary, and informed consent was implied through the act of completion. The primary mode of dissemination was the official mailing list of the Indian Society of Gastroenterology (ISG), which includes gastroenterologists affiliated with academic institutions, public and private hospitals, as well as standalone practices across the country. In addition, members of the study team actively circulated the survey link through WhatsApp groups, institutional communication platforms, and other professional networking channels commonly used by practicing gastroenterologists in India.

To ensure broad geographic and institutional representation, targeted efforts were made to encourage participation from practitioners across all 5 major geographic zones of India. For the purpose of regional analysis, respondents were categorized into 5 geographic zones: North, South, East, West, and Central. The North Zone included Punjab, Haryana, Himachal Pradesh, Jammu & Kashmir, Chandigarh, Delhi, and Rajasthan. The South Zone comprised Tamil Nadu, Kerala, Karnataka, Andhra Pradesh, and Telangana. The East Zone included West Bengal, Odisha, Bihar, Jharkhand, Assam, and Arunachal Pradesh. The West Zone encompassed Gujarat, Maharashtra, and Goa, while the Central Zone included Uttar Pradesh, Uttarakhand, Madhya Pradesh, and Chhattisgarh.

The survey remained open for a 10-week period (from 20 December 2024 to 28 February 2025), during which periodic reminders were issued to enhance response rates. No financial or material incentives were offered for participation.

To maintain data quality and integrity, the following measures were implemented: (1) Google Forms settings were configured to restrict multiple submissions from a single email address, minimizing the possibility of duplicate entries; (2) all survey questions were designated as mandatory, thereby preventing submission of incomplete responses; (3) manual inspection of metadata was conducted to identify any potential duplication, and no duplicates were found; and (4) all responses were collected anonymously to promote honest and unbiased reporting.

3. Data Management and Statistical Analysis

Survey data were automatically compiled through Google Forms and exported into Microsoft Excel (Microsoft Corporation, Redmond, WA, USA) for data cleaning and coding. Descriptive statistics were used to summarize response frequencies, and results were expressed as proportions or percentages of total responses. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA).

Survey Respondents and Regional Distribution

A total of 228 responses were obtained from members of the ISG who were invited to participate in the survey. The regional distribution of respondents was as follows: North India (n=71, 31.14%), South India (n=69, 30.26%), West India (n=35, 15.35%), Central India (n=25, 10.96%), and East India (n=28, 12.28%). The 228 respondents represented 179 institutions across India, distributed as follows: North India (n=60), South India (n=59), West India (n=21), East India (n=19), and Central India (n=20).

1) Section 1: Practice Setting

The majority of respondents were affiliated with corporate hospitals (n=76, 33.33%), followed by teaching hospitals (n=68, 29.82%). Fifty-five respondents (24.12%) were in individual or group private practice, while 29 (12.71%) worked in government hospitals (Table 1).

Table 1.

Respondent Characteristics (n=228)

2) Section 2: ASUC Caseload and Initial Management

The majority of respondents (n=115, 50.43%) reported consulting up to 20 patients with IBD per month, while 29 (12.71%) reported seeing more than 50 IBD patients monthly. With respect to ASUC case volume, in instances where multiple respondents belonged to the same institution, their responses regarding the number of ASUC patients managed annually were averaged, and the institution was treated as a single reporting unit to avoid duplication. Among the total participating centers, 56 institutions (31.28%) reported managing 5 to 10 ASUC cases per year, 45 institutions (25.13%) managed 11 to 20 cases, and 49 institutions (27.37%) reported managing fewer than 5 cases annually. Notably, 10 institutions (5.58%) reported managing more than 50 ASUC cases per year. On average, ASUC accounted for 3.8% (± 3.3%) of the total IBD caseload. Region-wise, the proportion of ASUC cases was highest in North India and Central India (4.4% ± 3.4% and 5.1% ± 4.5%, respectively), and lowest in South and West India (3.5% ± 3.6% and 2.7% ± 1.9%, respectively). Among individual or small group practitioners, 23 of 55 (41.81%) attended 5 to 10 ASUC cases annually. In contrast, among respondents from government, corporate, or teaching hospitals, 51 of 173 (29.47%) reported seeing 11 to 20 ASUC cases annually, with 12 (6.93%) managing over 50 cases. Regionally, the distribution of ASUC case volume varied across zones. In North India, the majority of institutions (19 out of 60; 31.67%) reported managing 11 to 20 ASUC patients annually, while 7 institutions (11.67%) reported seeing 21 to 50 cases per year. In South India, most institutions reported lower caseloads, with 22 out of 59 (37.29%) managing fewer than 5 cases annually, and 18 (30.51%) managing 5 to 10 cases. In the Western and Central regions, ≤10 ASUC cases per year were reported by 71.42% (15 out of 21) and 45% (9 out of 20) of institutions, respectively. In East India, 6 out of 19 institutions (31.58%) reported managing 5 to 10 ASUC patients per year (Fig. 1). The Truelove and Witts criteria was the most commonly used diagnostic tool (n=169, 74.12%), followed by the Mayo score (n=50, 21.92%). Nutritional assessment was always performed by 89 (39.03%) respondents, while 65 (28.50%) never assessed the nutritional status, and others performed occasionally (n=74, 32.45%). Body mass index was the most commonly used tool (n=201, 88.15%), followed by mid upper arm circumference (n=73, 32.01%), handgrip strength (n=64, 28.07%), and triceps skinfold thickness (n=44, 19.29%) to assess the nutritional status. The most frequently prescribed mode of nutrition was semisolid kitchen food (n=58, 25.43%), followed by exclusive enteral nutrition (EEN) and partial enteral nutrition (45 each, 19.73%). Thirty respondents (13.15%) reported keeping patients nothing by mouth (NPO) for 1 to 7 days. The regional variations in the mode of nutrition are summarized in Fig. 2. Hydrocortisone was the preferred first-line IVCS (n=188, 82.45%), followed by methylprednisolone (n=20, 8.77%). The use of oral corticosteroids, such as prednisolone (n=15, 6.57%) and budesonide (n=4, 1.75%), was also reported. Low molecular weight heparin (LMWH) was always co-prescribed by 95 (41.66%) respondents while 62 respondents (27.19%) reported never prescribing LMWH. While 182 (79.82%) respondents had access to gastrointestinal surgeons specializing in IBD, only 66 (28.94%) reported involving them within 24 hours of hospitalization.

Fig. 1.

Estimated number of acute severe ulcerative colitis cases managed annually across institutions in India. The data represent institution-level estimates. In cases where multiple respondents were from the same center, responses were averaged, and the institution was considered a single reporting unit to avoid duplication and overestimation of patient volume.

Fig. 2.

Regional variations in the preferred mode of nutritional support in patients with acute severe ulcerative colitis.

5) Section 5: Assessment of Response and Rescue Therapy

The Oxford criterion was the most commonly used (150, 65.78%) to monitor response to IVCS, followed by the Mayo score (48, 21.05%) and the All India Institute of Medical Sciences index (18, 7.89%). Most respondents assessed response on day 3 (173, 75.87%), followed by day 5 (26, 11.40%) and day 7 (6, 2.63%). Regarding patient’s acceptance for rescue therapy, 125 (54.82%) respondents noted that fewer than 50% of patients agreed to rescue treatment. Of these, 79 (34.64%) reported that only <20% of their patients had prompt acceptance for rescue therapy. There were no significant regional variations observed, as a comparable proportion of respondents from each zone reported that <20% of their patients had prompt acceptance for rescue therapy: 27 (38.02%) from North India, 22 (31.88%) from South India, 12 (34.28%) from West India, 8 (28.57%) from East India, and 10 (40%) from Central India. Infliximab was the most preferred rescue agent (149, 65.35%), followed by tofacitinib (n=55, 24.12%). Only 3 respondents (1.31%) opted for surgery as first-line rescue therapy after failure of IVCS. In the experience of the respondents, patients, however, chose either infliximab (n=99, 43.42%) or tofacitinib (98, 42.98%) as the preferred rescue therapy. Among the respondents who ever used cyclosporine (n=119, 52.19%), 2 mg/kg was the preferred dose (n=94, 78.99%). The facilities for therapeutic drug monitoring for cyclosporine were available to only 19 (8.33%) respondents. Rescue therapy was usually initiated on day 5 (96, 42.11%), followed by day 3 (n=59, 25.88%) and day 7 (n=57, 25.00%). Fourteen respondents (6.14%) reported initiating rescue therapy on or beyond day 10 (Fig. 3). The perceived patient-related barriers to rescue therapy included cost (n=215, 94.29%), stigma associated with surgery (n=103, 45.17%), and concerns about the risk of infections (n=91, 39.91%). Physician-related barriers majorly included cost (n=201, 88.15%) and the risk of infections (n=143, 62.71%) (Fig. 4). The response to rescue therapy was most commonly assessed on day 3 (n=84, 36.84%) following the administration of the drug, followed by days 7 (n=72, 31.58%), and day 5 (n=51, 22.37%). Twenty-one respondents (9.21%) assessed response to rescue therapy beyond day 10 (Fig. 5A). In case of failure of first line rescue therapy, 106 (46.49%) respondents considered sequential medical rescue therapy, while 122 (53.50%) preferred surgery as second line rescue therapy. The majority of the respondents (n=200, 87.71%) reported that <5 patients underwent ileal pouch-anal anastomosis (IPAA) surgery annually in their center; only 2 respondents (0.87%) reported more than 20 such surgeries per year (Fig. 5B).

Fig. 3.

Timing of initiation of rescue therapy in acute severe ulcerative colitis, stratified by respondent region.

Fig. 4.

Reported barriers to the use of rescue therapy in the management of acute severe ulcerative colitis.

Fig. 5.

(A) Distribution of responses regarding the timing of assessment of response to rescue therapy; (B) distribution of responses on the number of ileal pouch-anal anastomosis (IPAA) procedures performed annually.

This nationwide web-based survey provides a comprehensive

snapshot of the real-world practices and clinical decision-making processes among Indian gastroenterologists in the management of ASUC. The findings highlight several important gaps, regional variations, and areas for improvement to enhance adherence to evidence-based care (Table 2).

Table 2.

Current Guideline Recommendations and Observed Practice Gaps in Key Areas of the Management of ASUC

A majority of respondents in our study reported up to 20 patients with ASUC annually. This suggests that the overall burden of ASUC in India remains high, likely owing to the country’s large population base and an increasing prevalence of UC. Notably, regional disparities were observed in patient volume. Respondents from North India and Central India reported seeing a greater number of ASUC cases annually compared to their counterparts in west and South India. These regional differences are intriguing. While we did not specifically collect data on the reasons behind these regional differences, a few plausible explanations can be considered. Referral patterns may play a role, as tertiary centers in North India and Central India often serve large catchment areas and may receive a higher proportion of severe cases. It is also worth noting that UC is known to be more prevalent in North India, whereas Crohn’s disease appears to be more common in South India [5]. This epidemiological pattern may partially explain the higher ASUC burden in the northern regions.

Nearly one-third of respondents reported never assessing the nutritional status of patients with ASUC. Malnutrition is a known predictor of poor outcomes in ASUC, including higher rates of complications, prolonged hospitalization and colectomy [10-13]. Nutritional assessment and support should therefore be an integral part of initial management. In terms of dietary practices, the majority of clinicians prescribed a semisolid kitchen-based diet during hospitalization. EEN was also used by approximately 20% of respondents, which is noteworthy given emerging evidence, including an Indian trial, demonstrating the potential benefit of EEN in improving response to IVCS [8]. At the same time, the continued practice of keeping patients NPO, reported by 13% of respondents, is concerning. Prolonged NPO status can lead to negative energy balance, increased catabolic stress, and worsened nutritional status [14]. This practice is inconsistent with current international guidelines [14,15]. Early enteral feeding, where feasible, is advocated to preserve gut integrity and improve prognosis. The persistence of outdated practices such as NPO in ASUC underscores the need for targeted education, dissemination of updated guidelines, and system-level interventions to promote optimal, evidence-aligned care.

Thromboprophylaxis with LMWH is recommended in all hospitalized patients with ASUC due to the elevated risk of thromboembolic events [16]. This risk is amplified by systemic inflammation, immobilization, dehydration, and corticosteroid use. Despite this, nearly one-third of respondents reported not routinely prescribing LMWH–an alarming gap in care that may expose patients to preventable, potentially lifethreatening complications. This observation highlights the urgent need for enhanced awareness, ongoing medical education, and active dissemination of guideline-based recommendations related to thromboprophylaxis in ASUC.

Timely involvement of the colorectal surgeons, ideally within 24 hours of hospitalization, is a key recommendation in the management of ASUC [17]. Early involvement of surgical teams in ASUC facilitates comprehensive multidisciplinary planning, helps set realistic expectations, and ensures that patients requiring colectomy receive it at the optimal time. Despite this, only 29% of respondents in the current study reported engaging surgical colleagues within this critical window. This low uptake may reflect a broader hesitancy among gastroenterologists in India to initiate early surgical discussions, potentially influenced by several interlinked factors. These include patient and family reluctance, limited acceptance of colectomy, and the deeply rooted societal stigma surrounding stomas and bowel surgery. Additionally, lack of structured multidisciplinary care pathways and limited access to experienced colorectal surgeons in some settings may further contribute to delays.

The limited utilization of IUS among respondents, reported at 16.66%, likely reflects both infrastructural limitations and the restricted availability of formal training opportunities in this modality across India. Currently, structured programs such as the International Bowel Ultrasound certification are not widely accessible within the country. Moreover, there is a lack of national-level training initiatives or incorporation of IUS into institutional gastroenterology fellowship curricula. This limited exposure may contribute to the underuse of IUS in the management of ASUC, despite its established clinical utility. Encouragingly, a dedicated IUS group is currently being established within the country (Colitis and Crohn’s Foundation [India], personal communication, July 2025). This initiative is anticipated to enhance awareness, facilitate structured training, and support the broader adoption of IUS in clinical practice.

Approximately 21% of respondents did not report performing pre-treatment screening for LTB, which raises a significant safety concern, particularly in high tuberculosis-burden settings such as India. This highlights a critical gap in adherence to established guidelines and underlines the need for greater awareness and reinforcement of TB screening protocols before initiation of anti-TNF therapy. Among respondents who reported performing pre-treatment screening for LTB, the majority utilized either the interferon γ release assay, the Mantoux tuberculin skin test, or a combination of both. However, fewer than half reported routinely incorporating X-ray or CT of the chest tools that are instrumental in detecting latent or subclinical pulmonary TB, particularly in individuals with prior exposure or atypical presentations. This is especially concerning in the Indian context, where TB remains endemic and the risk of reactivation is significantly increased with infliximab and tofacitinib [18,19]. Current guidelines advocate for a multimodal approach to LTB screening, combining immunologic and radiologic methods [20]. Overreliance on a single modality may lead to underdiagnosis, delayed treatment, and complications. Hence, there is a need to promote comprehensive and standardized screening protocols for LTB.

C. difficile testing was reported by the vast majority (94%) of respondents, using validated diagnostic assays such as glutamate dehydrogenase, toxin A/B, and PCR. This is reassuring and indicates awareness of this important entity in ASUC. In contrast, testing for CMV, another important secondary cause of steroid-refractory colitis, was markedly less frequent. Only 32.89% of respondents reported routinely obtaining colonic biopsies for CMV testing, while 21.49% relied on blood PCR, which has limited sensitivity for diagnosing localized intestinal CMV infection [21,22]. This is concerning, as missed or delayed diagnosis of CMV colitis can lead to prolonged inflammation, inappropriate escalation of immunosuppression, and adverse outcomes including colectomy. Histopathology with immunohistochemistry or tissue PCR remain the standard investigations for diagnosing CMV colitis and should be systematically pursued in all cases, especially in steroid non-responders.

A critical finding from this survey was the low rate of patient acceptance for rescue therapies in the management of ASUC. More than half of the respondents (55%) reported that fewer than 50% of patients had acceptance for escalation to rescue therapies such as infliximab or cyclosporine or colectomy, and over one-third observed acceptance rates below 20%. This pattern was consistent across geographic regions, highlighting a systemic challenge rather than isolated institutional issues. The reasons cited were multifactorial. Patient-related barriers included the high cost of biologics, and poor acceptance of biologics and pervasive stigma surrounding colectomy. Cost remains a major barrier to the uptake of rescue therapies among patients with ASUC in India. Insurance coverage for biologics and other advanced therapies is variable, with limited support from insurers, often subject to caps or prior authorization. Also, health insurance penetration in India remains low, leaving many patients uninsured or underinsured. Consequently, the high out-of-pocket expenses associated with these treatments likely contribute to the reluctance or inability of patients to pursue rescue therapy. On the provider side, physicians echoed similar concerns, sometimes reinforcing patient hesitancy due to their own apprehensions. These findings highlight the urgent need for a multipronged strategy to overcome both patient and physician resistance. This should include structured education programs that clearly communicate the rationale, safety, and potential benefits of rescue therapies; individualized counselling to address fears and misconceptions; and systemic efforts to improve affordability, such as inclusion of biologics in government insurance schemes, patient assistance programs, or hospital-supported subsidies. Without such initiatives, timely and appropriate administration of rescue therapy in ASUC will remain underutilized, potentially compromising outcomes.

The timing of rescue therapy initiation in ASUC also revealed substantial deviations from established recommendations. While current recommendations typically advocate for initiation of rescue therapy by day 3 in patients not responding to IVCS, only 26% of respondents reported adhering to this timeline [23,24]. The majority delayed initiation until day 5 or 7, and a notable proportion extended this even beyond day 10. Some clinicians may struggle with prognostication or feel uncertain about when steroid non-response is definitive, particularly in the absence of rapid biomarkers or uniform scoring tools. Compounding these challenges is the lack of absolute consensus in the literature regarding the optimal timing for rescue therapy. While most expert bodies support early intervention, particularly by day 3, a recent Delphi consensus suggested that response assessment can extend up to 14 days, introducing ambiguity into clinical decision-making [25]. These findings highlight the necessity of region-specific data, algorithm-based approaches, and real-world studies to clarify optimal timing thresholds for administration of rescue therapy.

In the event of failure of first-line rescue therapy, 46% of respondents reported considering sequential medical rescue therapy while 53% opted for colectomy. This distribution is notable and stands in contrast to prevailing practices in Western countries, where early surgical intervention is generally favored following failure of a first-line rescue agent [2,4]. The inclination toward sequential therapy in the Indian context may be reflective of a deeply rooted aversion to surgery. While sequential therapy can be considered in select, carefully monitored patients, it is associated with increased risk of complications, including infections, delayed surgery, and poor postoperative outcomes if colectomy is ultimately required in a deteriorating clinical state [26-29].

88% of respondents reported that fewer than 5 patients annually underwent IPAA surgery at their centers. The dominance of low volume surgical centers could indicate both hesitancy in recommending surgery and limited availability of trained colorectal surgeons proficient in IPAA procedures, especially outside major tertiary care settings. These findings highlight the need to enhance surgical infrastructure and build capacity in colorectal expertise [30].

Institutional factors play a critical role in the management of ASUC in real-world settings. In India, differences across hospital types (corporate, teaching, private, and government) affect both the availability and affordability of advanced therapies and surgical interventions. Corporate and private hospitals may provide greater access to biologics and specialized surgical care; however, the associated costs can be prohibitive and are often not fully covered by insurance. In contrast, government and teaching hospitals typically offer more cost-subsidized care but may be constrained by limited resources, infrastructure, or delays in access to optimal therapies. Additionally, IBD-specific expertise remains limited and unevenly distributed across regions. These institutional disparities are central to understanding the ongoing challenges in ensuring equitable access to care.

A key strength of our study lies in its broad national scope, capturing responses from practicing gastroenterologists across diverse geographic regions of India. This allowed for a comprehensive and representative overview of real-world practices in the management of ASUC. In the context of a rising IBD burden in India, the survey provides timely and relevant data that can inform targeted interventions, enhance physician education, and support the contextual adaptation of international guidelines to the Indian healthcare setting. This study also serves as a roadmap for future follow-up studies conducted after continuous medical education activities that would enrich our understanding of the evolving trends, perspectives and outcomes of ASUC in the coming years. However, there are certain limitations that warrant consideration. First, the survey was disseminated exclusively to members of the ISG, which may have constrained the diversity of perspectives, particularly those of other healthcare professionals involved in the multidisciplinary management of ASUC, including colorectal surgeons, internists, and emergency medicine physicians. It is noteworthy that the survey respondents were predominantly general gastroenterologists rather than dedicated IBD specialists. However, this reflects real-world clinical practice, where the majority of patients with ASUC are managed by general gastroenterologists. Additionally, the reliance on self-reported data introduces the possibility of response bias, as respondents may have overestimated adherence to best practices or guideline-based care. Furthermore, the study did not incorporate an objective validation component, such as clinical audits or patient chart reviews, to corroborate the reported practices. Despite these limitations, we believe the findings are reflective of prevailing clinical practices in India and provide a valuable foundation for identifying practice gaps and informing quality improvement initiatives.

In conclusion, this nationwide survey offers valuable insights into the current landscape of ASUC management in India, highlighting real-world clinical practices, regional variations, and levels of adherence to established guidelines. While many encouraging practices were observed, several critical gaps remain. These include suboptimal attention to nutritional assessment, inadequate implementation of thromboprophylaxis, and poor acceptance of rescue therapies and inconsistent timing of initiation of rescue therapy. These observations highlight the urgent need for comprehensive, multifaceted strategies such as continuous medical education, improved access to multidisciplinary care, strengthened patient-provider communication, and the development of contextually relevant clinical pathways. Reducing variability in care delivery and promoting adherence to evidence-based practices must be prioritized to improve patient outcomes. Moving forward, efforts should be directed toward generating region-specific data, fostering collaborative clinical and research networks, and ensuring equitable access to high-quality care for all patients with ASUC across the country.