Signs and Symptoms
- Crohn disease can present with any clinical correlates of chronic inflammatory, fibrostenotic, or fistulizing illness
- UC may begin subtly or as catastrophic illness
- Constitutional, GI, and extraintestinal manifestations are common with both Crohn and UC
History
- Constitutional:
- Crohn:
- Low-grade fever
- Night sweats
- Weight loss
- Fatigue
- Pediatric: Growth or pubertal delay
- UC:
- Fever usually only in fulminant disease
- Weight loss/fatigue
- GI:
- Abdominal pain/tenderness - Crohn disease:
- Episodic
- Periumbilical; may localize to right lower quadrant (RLQ) with ileal disease
- Generalized with more diffuse intestinal involvement
- Can localize to area of intra-abdominal abscesses or fistulous involvement
- Tenderness and distension suggest obstruction or toxic megacolon
- Abdominal pain/tenderness - UC:
- More generalized than Crohn disease
- Often limited to predefecatory period
- Tenderness with distension - suspect toxic dilation
- Stool:
- Crohn disease:
- Mild, loose stool, rarely >5/d
- ∼50% bloody
- UC:
- Diarrhea is variable, can be severe
- Vast majority are bloody, sometimes with severe hemorrhage
- Mucus
- Tenesmus and urgency are common
- Nausea/vomiting:
- Crohn disease:
- Obstruction common with ileocolonic disease
- UC:
- Obstruction rare
- Diminished bowel sounds with toxic dilation
- Liver:
- Sclerosing cholangitis can be seen
- Cholelithiasis can be seen in 35-60% of Crohn
- Renal:
- Nephrolithiasis
- Obstructive hydronephrosis
- Musculoskeletal:
Physical Exam
- Perianal:
- Crohn disease:
- Perianal abscesses
- Fissures - characteristically painless
- Fistulas - seen in up to 50% of patients with colonic disease
- May present prior to other manifestations
- UC:
- RLQ pain/mass often mistaken for appendicitis
- Severe toxicity/abdominal pain - must exclude toxic megacolon
- Extraintestinal:
- Eye:
- Uveitis
- Episcleritis
- Keratitis
- Oral:
- Dermatologic:
- Erythema nodosum
- Pyoderma gangrenosum
Essential Workup
- May present as initial onset of disease or exacerbation of existing disease
- Maintain high index of suspicion because of subtle presentation of Crohn disease
Diagnostic Tests & Interpretation
Lab
- Nothing diagnostic
- CBC:
- Anemia secondary to chronic or acute blood loss
- Electrolytes, BUN/creatinine, glucose
- Stool exam:
- Occult blood
- Clostridium difficile
- Fecal leukocytes may be present
- O & P and culture to rule out infectious cause of enteritis
- ESR is always elevated
- Newer, investigational, serologic tests may have use as adjunctive diagnostic aids, screening tests, or predictors in therapy
Imaging
- Lifetime radiation dose is cumulative and IBD patients have repeated exposure; consider MRI when available
- Upright chest and abdominal radiographs for:
- Toxic megacolon (>6 cm dilation)
- Obstruction
- Air in wall of colon (may indicate impending perforation)
- Perforation - subdiaphragmatic air or free air outlining liver or gall bladder
- CT abdomen/MRI:
- Distinguish abscess from localized inflammatory mass in Crohn
- Colonoscopy with biopsy can confirm diagnosis of UC or Crohn:
- Can be withheld with severe symptoms owing to perforation risk
- Contrast imaging of small bowel, especially terminal ileum, may confirm diagnosis of Crohn
- MRI can be useful in Crohn perianal disease and avoids ionizing radiation
Differential Diagnosis
- Infectious enteritis
- Pseudomembranous colitis (C. difficile)
- Appendicitis
- Diverticulitis
- Diverticulosis
- Functional bowel disease
- Lymphoma involving bowel
- Ischemic colitis
- Gonococcal or chlamydial proctitis
- HIV
- Colon cancer
- Vasculitis
- Amyloidosis
Prehospital
Vital sign stabilization as per BLS
Initial Stabilization/Therapy
- IV 0.9% NS volume replacement if dehydrated
- Transfusion if significant blood loss
ED Treatment/Procedures
- Nasogastric (NG) suction if obstruction or toxic dilation suspected
- Broad-spectrum antibiotics for fulminant UC or suspected perforation
- Consider steroid replacement if stress doses are required for those recently on oral steroids
- Surgical evaluation indications:
- Free perforation
- Intestinal obstruction
- Massive, unresponsive hemorrhage
- Toxic dilation:
- Not an absolute indication for surgery
- Intensive medical management with small bowel decompression and close radiographic monitoring and surgical consultation
- Walled-off perforation with abscess:
- Usually not an indication for emergent surgery
- Careful observation for peritonitis
- Medical therapy:
- Treatment is usually not initiated unless diagnosis is already established
- Refill or restart medications in patient with known disease
- ED-prescribed medical regimen should be individualized, and consultation with gastroenterologist strongly recommended:
- Aminosalicylate (sulfasalazine/mesalamine) in mild to moderate case
- Antidiarrheal agent (diphenoxylate) is used - but withhold if severe disease or suspect toxic megacolon
- Steroid (prednisone, budesonide or hydrocortisone enema, ACTH) is used for moderate to severe disease
- Antibiotics (metronidazole and /or ciprofloxacin) aid in treatment of Crohn with colon/perineal involvement
- Immunosuppressive agents (azathioprine, methotrexate) are used in severe disease
- Monoclonal antibodies neutralize cytokine tumor necrosis factor (TNF)-α and inhibit binding to TNF-α receptors (infliximab [Remicade]). Used as parenteral therapy in disease unresponsive to other modalities. Not an ED drug, but be aware of potential severe adverse reactions, infusion reactions, autoimmune diseases, and infections
Pediatric Considerations |
| If nonaccidental trauma is suspected, prompt referral to appropriate child protective agencies is required along with medical treatment |
Medication
- Ciprofloxacin: 500 mg (peds: 10-20 mg/kg q12) PO q12h
- Hydrocortisone enema: 60 mg per rectum
- Mesalamine enemas: 1-4 g retention enema - retain overnight. Adult
- Mesalamine suppository: 500 mg per rectum b.i.d. Adult
- Mesalamine tablets:
- Asacol 800 mg PO t.i.d
- Pentasa 1,000 mg PO q.i.d
- Methylprednisolone: 125-250 mg IV load (peds: 2 mg/kg IV load, maintenance as adult), then 0.5-1 mg/kg/dose q6h for 5 d
- Metronidazole: 250-500 mg (peds: 30 mg/kg/24 hr) PO t.i.d
- Prednisone: 40-60 mg (peds: 1-2 mg/kg) PO daily
- Sulfasalazine (Azulfidine): 500 mg (peds: 30 mg/kg) PO q.i.d
Disposition
Admission Criteria
- Surgical indication:
- Massive, unresponsive hemorrhage
- Perforation
- Toxic dilation
- Obstruction
- Severe flare-up:
- Electrolyte imbalance
- Severe dehydration
- Severe pain
- High fever
- Significant bleeding
Discharge Criteria
- Initial presentation of diarrhea, mild pain, without toxicity, with close follow-up
- Mild to moderate exacerbation of known disease without obstruction, severe bleeding, severe pain, dehydration, with close follow-up, on renewed therapy or with addition of steroid
Issues for Referral
Extraintestinal manifestations
Follow-up Recommendations
Gastroenterologist or primary care as managing physician with surgical consultation as indicated
- BrowneAS, KellyCR. Fecal transplant in inflammatory bowel disease . Gastroenterol Clin North Am. 2017;46:825-837.
- DuijvesteinM, BattatR, Vand e CasteeleN, et al. Novel therapies and treatment strategies for patients with inflammatory bowel disease . Curr Treat Options Gastro. 2018;16:129-146.
- KhannaR, JairathV, FeaganBG. The evolution of treatment paradigms in Crohn's disease: Beyond better drugs . Gastroenterol Clin N Am. 2017;46(3):661-677.
- ShahSC, ColombelJF, Sand sBE, et al. Mucosal healing is associated with improved long-term outcomes of patients with ulcerative colitis: A systematic review and meta-analysis . Clin Gastroenterol Hepatol. 2016;14(9):1245e8-1255e8.
See Also (Topic, Algorithm, Electronic Media Element)