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Information ⬇

Author(s): Sophia Savva and Andrew Dixon

Consider a flare of inflammatory bowel disease (IBD) (Appendix 76.1) in patients presenting with:

Assessment and management of the patient presenting with undifferentiated acute diarrhoea are given in Chapter 22.

Priorities ⬆ ⬇

Establish the diagnosis by clinical assessment (Table 76.1) and urgent investigation (Table 76.2).

Key differentials to consider are:

Where there is any diagnostic doubt, request colonoscopy. Limited examinations can often be performed without bowel preparation. Biopsies are often key to establishing the diagnosis and differentiating between Crohn's colitis and ulcerative colitis, and can reveal the presence of cytomegalovirus and other infections. Other pathologies such as colorectal cancer and ischaemic colitis can also be identified.

Immediate Management of a Flare of Ibd

  • Establish a stool chart. This is essential for assessing progress. A sudden reduction in stool production should be followed up with an abdominal film to rule out toxic megacolon.
  • Prescribe low-molecular-weight heparin thromboprophylaxis and anti-embolism stockings. This should be done even in patients with rectal bleeding as long as they are not anaemic or haemodynamically compromised. Active inflammatory bowel disease confers a very high thromboembolic risk.
  • Prescribe hydrocortisone 100 mg 6-hourly IV.
  • Prescribe a 5-ASA for colitis, which can be given rectally in limited left-sided disease. These are not effective drugs for use in small-bowel Crohn's disease.
  • Advise a low residue diet.
  • If proximal constipation is seen on the abdominal film, prescribe laxatives.
  • Discontinue opioids, NSAIDs and anti-diarrhoeal agents, as these can precipitate toxic megacolon.
  • Involve the gastroenterology team and the inflammatory bowel disease nurse.
  • Well patients with no high-risk features can be managed as outpatients, with oral steroids in the form of prednisolone or budesonide.
  • Treat any underlying or suspected infection.
  • Patients with signs of peritonitis, toxic dilatation, fistulating or obstructing disease should be referred urgently to the surgical team.

Further Management ⬆ ⬇

Outline

 

Ulcerative Colitis!!navigator!!

This is summarized in Figure 76.1.

Imaging

Abdominal X-ray should be done to rule out toxic dilatation and proximal constipation. It can also often give an idea as to the extent of the disease.

Other forms of imaging are rarely necessary. Occasionally a CT abdomen may be indicated if complications are suspected, but as IBD patients have a high lifetime exposure to ionizing radiation, this should be avoided wherever possible.

Nutrition

Maintenance of caloric intake is essential to promote bowel microbiome health and prevent weight loss, but during periods of active disease, a low-residue diet should be given to prevent further disease exacerbation.

Drug therapy

The initial treatment of an acute flare is with corticosteroid. In a severe flare, oral steroid is not adequately absorbed by inflamed mucosa, so parenteral treatment should be given initially. If the response is good, oral steroid (e.g. prednisolone 40–60 mg daily, with gastric and bone protection) can be substituted after 72 hours, and can be given from the outset in mild-moderate flares.

If a severe flare does not respond to parenteral corticosteroid, ciclosporin or infliximab may be used. This must always be under the supervision of a gastroenterologist.

Surgery

Colectomy remains the most effective treatment for ulcerative colitis. However, it should be reserved for the patient in whom medical treatment has failed. Of vital importance is the firm establishment of the diagnosis of ulcerative colitis (UC) as opposed to Crohn's colitis, as colectomy is curative in the former but not in the latter. Surgical intervention in UC carries a much better prognosis when performed as a planned procedure rather than as an emergency. This is why it is important to involve the surgical team early, and also why sometimes certain drugs such as ciclosporin can be given as a bridge to surgery.

Crohn's Disease!!navigator!!

Imaging

In small bowel Crohn's disease, further imaging may be warranted. Consider small-bowel ultrasound scanning, MRI enterocleisis or CT of the abdomen to look for collections, obstructions, perforations or fistulas.

When requesting imaging in Crohn's disease remember that these patients are often young, with a lifelong illness, and their exposure to radiation is often significant over the years. Consider imaging techniques that do not involve exposure to ionizing radiation where available.

Capsule endoscopy

Crohn's disease can often present in an occult fashion with iron-deficiency anaemia, non-specific abdominal pain, nausea and vomiting, or weight loss. In these cases, capsule endoscopy may be useful to image the small bowel, but this is usually performed on an outpatient basis.

Nutrition

Nutritional assessment is an essential part of management, particularly if there is a history of weight loss or multiple surgeries resulting in a short gut. Elemental diets have been shown to be useful in treating complicated Crohn's disease, especially in the presence of strictures, but compliance is low. In severe cases supplementary NG feeding or even parenteral feeding may become necessary, but this should always be instigated on the advice of a nutrition consultant.

Drug therapy

The initial treatment of an acute flare is with corticosteroid. In a severe flare, oral steroid is not adequately absorbed by inflamed mucosa, so parenteral treatment should be given initially. If the response is good, oral steroid (e.g. prednisolone 40–60 mg daily, with gastric and bone protection) can be substituted after 72hours, and can be given from the outset in mild-moderate flares.

If a severe flare does not respond to parenteral corticosteroid, ciclosporin or infliximab may be used. This must always be under the supervision of a gastroenterologist.

Surgery

The place of surgery in the management of Crohn's disease is less clear cut than in UC. Endoscopic recurrence of the disease post-surgery is around 80% after the first year, and for this reason surgery is reserved for complications of Crohn's disease or disease refractive to medical management. In general, surgery focuses on removing as little of the bowel as possible, as over many years these patients can end up with a short gut and the complications that follow.

Further Reading ⬆

National Institute for Health and Care Excellence (2012) Crohn's disease: management. Clinical guideline (CG152). https://www.nice.org.uk/guidance/cg152?unlid = 5300026042016102323343.

National Institute for Health and Care Excellence (2013) Ulcerative colitis: management. Clinical guideline (CG166). https://www.nice.org.uk/guidance/cg166.

Seah D, De Cruz P (2016) Review article: the practical management of acute severe ulcerative colitis. Aliment Pharmacol Ther 43, 482–513.