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Management of Severe Exacerbation of Inflammatory Bowel Disease

Assessment / monitoring

On admission

  • Stool culture and Clostridium difficile toxin.
  • Stool chart (kept by nursing staff).
  • BP / pulse / temperature - frequency depends on initial findings.
  • Bloods – FBC; CRP or ESR; U&Es; LFTs; blood cultures.
  • X-ray – plain film of abdomen.
  • If features suggesting severe disease present, seek immediate senior review. Features of severe disease are:
    • >6 bloody stools per day and systemic toxicity with at least one of:
    • temperature >37.8°C
    • pulse >90bpm
    • haemoglobin <105g/L or C-reactive protein >30mg/L
  • Unprepared sigmoidoscopy in new patient.

General management and treatment options

  • Avoid anti-diarrhoeal agents
  • Give IV fluids
  • Give hydrocortisone sodium succinate IV infusion 100mg every 6 hours or methylprednisolone sodium succinate IV 30mg infusion every 12 hours. Check which drug is used on your site before prescribing.
  • Give low residue diet / oral fluids.
  • Give high calorie supplements
  • If Hb below normal – replace deficient haematinics and consult with the gastroenterology team to advise on the need for transfusion or parenteral iron infusion.
  • High risk of venous thromboembolism – give thromboprophylaxis (unless contraindicated):
    enoxaparin SC 40mg once daily or refer to Thromboprophylaxis dose guide in renal impairment.
  • Involve gastroenterologist / gastrointestinal surgeon

Note: Caution with:

  • Narcotics*
  • Antispasmodics*
  • Hypokalaemia
  • Barium enema

Discuss with radiologist / gastroenterologist.

*Patient with abdominal pain must be seen and assessed before prescribing analgesia.

Ongoing management

  • Monitor Hb, WCC, U&Es, CRP daily
  • Daily abdominal film whilst on IV steroid therapy and arrange surgical review if transverse or ascending colon diameter >6cm.
  • Light diet
  • A CRP >45 or the stool frequency >8 at day 3 are bad prognostic signs and senior review and/or surgical review should be undertaken immediately.

Drug treatment after 5–7 days

  • Change IV hydrocortisone to: prednisolone oral 40mg each day. Reduce no faster than by 5mg every 5–7 days. Normally there is gradual reduction over a 4–8 week period if CRP and stool frequency falling.
  • If ulcerative colitis add mesalazine oral (seek specialist advice if unsure):
      • Salofalk® MR granules 1.5-3g once daily or in three divided doses (or Salofalk® tablet 1.5-3g daily in three divided doses).

    Alternatives are:

    • Pentasa® MR tablets / sachets 2–4g once daily or
    • Octasa® MR tablets 2.4-4.8g per day in divided doses
  • Rectal preparations (e.g. mesalazine 1g suppositories / enemas) may be useful in proctitis, left sided disease and Crohn's disease of the rectum and anus. Seek specialist advice.

Discharge

Normally discharged when:

  • Non-toxic
  • Stool frequency decreased, consistency increased and macroscopic blood decreased
  • Lab parameters stable
  • Follow-up OPD appointment made

 

Guideline reviewed and content updated April 2021