Total colectomy is curative for ulcerative colitis. However, many pediatric patients are medically managed and may not require surgery. There are currently no available criteria to identify children who will benefit from early colectomy. The purpose of this review was to identify criteria associated with the need for colectomy. A 15-year review of patients at a major pediatric center with biopsy-proved ulcerative colitis was conducted. Age at the time of the first symptom, diagnosis, and surgery were recorded as well as steroid dependence, site of disease, extraintestinal manifestations, and family history. Seventy-three patients ranging in age from 1 to 18 years were identified. Thirty-seven patients (50.1%) required total colectomy before the age of 18. The average patient age at the time of the first documented symptom was 11.3 +/- 0.5 years. Among patients who were steroid dependent and had pancolitis, 73% required colectomy. Patients with these factors failed medical management 77% (27 of 35) of the time, and colectomy was performed within 3 years of diagnosis. The combination of steroid dependence and pancolitis was associated with an increased need for colectomy. In pediatric patients with these factors, early colectomy may limit the need to endure prolonged courses of medications and the disability allied with this disease.