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Management of Severe Exacerbation of Inflammatory Bowel Disease

Assessment / monitoring

On admission

  • Stool culture and Clostridium difficile toxin (three samples).
  • Stool chart (kept by nursing staff).
  • BP / pulse / temperature - frequency depends on initial findings.
  • Bloods – FBC; CRP or ESR; U&Es; coagulation; LFTs; haematinics and iron studies; blood cultures (if pyrexial).
    • If not done within the last year - blood borne virus screen, TB quantiferon, VZV and EbV IgG
    • If not done before - TTG and TPMT
  • MUST score - Dietician referral if MUST ≥2.  
  • Chest 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 the following:
    • temperature >37.8°C
    • pulse >90 beats/minute
    • Hb <105g/L or CRP >30mg/L
  • Consider unprepared sigmoidoscopy in new patient.

General management and treatment options

  • Avoid anti-diarrhoeal agents
  • Give IV fluids
  • Give methylprednisolone sodium succinate IV 30mg infusion every 12 hours. 
  • 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.  See Iron Deficiency Anaemia in Acute Care Guideline for guidance. 
  • High risk of venous thromboembolism – give thromboprophylaxis (unless contraindicated): enoxaparin SC 40mg once daily or refer to separate guidance if renal impairment or GGC guideline if extremes of body weight.
  • 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 >45mg/L 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 methylprednisolone 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.
  • Consider bone protection if long term / reducing steroids - prescribe appropriately.
  • Consider Pneumocystis jirovecii (PJP) prophylaxis (co-trimoxazole oral 480mg daily or 960mg 3 times/week) for patient on triple immunosuppression (e.g. thiopurine, steroid and biologic)
  • 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: November 2024

Page last updated: March 2025