Almost as many as 10% of patients with ulcerative colitis have late onset with the first flare occurring at 60-70 years of age. The course of the disease and the basic principles of management in geriatric populations do not differ from those in younger patients. However, elderly patients pose distinct problems in therapy choice. In middle-aged patients untreated severe ulcerative colitis has been reduced to <1% in specialized centers at the present time but is still high in the elderly. In general, the management requires close collaboration between gastroenterologists and surgeons. In adult patients, current evidence supports initial treatment with intravenous steroids. However, only 40% of patients show complete response after corticosteroid therapy and almost 30% come to colectomy. Cyclosporine still has a first place as salvage therapy because of its short half-life and its established short-term efficacy in about 70% of patients who fail steroids. The drug should be avoided in frail or elderly patients (especially over 80 years old) with significant comorbidity, and also where colectomy is likely to be necessary in the short to medium term. The long-term benefit of this therapy remains unsatisfactory as colectomy is often only delayed. Infliximab is the choice for those patients with a less severe colitis and less likelihood of urgent colectomy. Tacrolimus has only been used in one randomized controlled trial with similar results to cyclosporine. Surgery is still the definitive procedure for the treatment of ulcerative colitis in adult patients, and its timing is of paramount importance.