Intravenous corticosteroids are the mainstay of initial treatment of patients hospitalized with severe ulcerative colitis (UC). Response to intravenous corticosteroids should be assessed early, usually by day 3, using clinical, radiologic, and biochemical markers. Therapeutic alternatives for steroid-refractory cases should be considered early. Clostridium difficile is prevalent in hospitalized patients with UC flare and may require multiple testing to be detected. Unfractionated heparin should be administered for prophylaxis against venous thromboembolism even if the patient bleeds significantly. If available, an inflammatory bowel disease (IBD) team including a gastroenterologist and colorectal surgeon with expertise in IBD should be involved.