Key facts:
Authors: Natalie Acors and Jayne Eaden
Top Tip: Exclude toxic megacolon, obstruction and ischaemic colitis
Key Differential Diagnoses
- Acute gastroenteritis
- Ischaemic colitis (old, ill, arteriopath, AF)
- Diverticulitis/colonic carcinoma
Key Investigations
- FBC, ESR, CRP
- U+E, LFT, Bone, Glucose
- Stool culture (?C diff)
- AXR, ECG (?AF)
Key Treatment
- IV HYDROCORTISONE 100 mg qds or
- PO PREDNISOLONE 30 mg od
Key Management Decisions
- Steroids
- Surgery
Background
Recurrences of IBD often present to the Emergency Department
Introduction
- Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis (UC), is a relapsing and remitting condition characterized by chronic inflammation at various sites in the GI tract, which results in diarrhoea and abdominal pain
- 'Inflammatory colitis' is normally taken to mean colonic inflammation secondary to ulcerative colitis or Crohns Disease. Recurrences often present to the Emergency Department, or on medical take first
- The key management decision is whether to give/increase steroids
- Don't forget ischaemic colitis (elderly, AF and unwell) and clostridium difficile. Involve gastroenterology (and general surgery) early
Definition
- Chronic inflammatory diseases of the GI tract, usually relapsing/remitting
Pathology
UC
Epidemiology
- IBD affects people of all ages but usually begins before age 30, with peak incidence from 15 to 25. IBD may have a second smaller peak between ages 50 and 70; however, this later peak may include some cases of ischemic colitis
- UC prevalence 100-200/100,000. CD prevalence 50-100/100,000. A new onset of UC/CD is rare; relapses common. Recent foreign travel increases likelihood of IBD (not just gastroenteritis)
- IBD is most common in people of Northern European and Anglo-Saxon origin and is 2 to 4 times more common in Ashkenazi Jews than in non-Jewish whites. The incidence is lower in central and southern Europe and lower still in South America, Asia, and Africa
- Both sexes are equally affected. First-degree relatives of patients with IBD have a 4- to 20‑fold increased risk; their absolute risk may be as high as 7%. Familial tendency is much higher in CD than in UC. Several gene mutations conferring a higher risk of CD (and some possibly related to UC) have been identified
- Cigarette smoking seems to contribute to development or exacerbation of CD but decreases risk of UC. NSAIDs may exacerbate IBD
Causes
- Unknown
Types
- Proctitis (rectum only)
- UC: colon only (continuous disease)
- CD: anywhere in GI tract (and unaffected areas between active disease)
Risk factors
- Smoking (CD)
- Smoking cessation (UC)
Symptoms
- (Gradual onset) diarrhoea (vs gastroenteritis, usually rapid), with blood, mucus
- Urgency, tenesmus
- Abdominal pain, weight loss
- Obstructive symptoms
- Abdominal mass (especially RIF)
- Symptoms from extraintestinal problems (see below)
Key questions
- "When did the symptoms start?"
Signs
- None, or
- Fever, tachycardia, abdominal distension (including perforation)
- Mass (especially RIF in CD)
- Obstructive signs
- Perianal (CD)
- Note: look for extraintestinal: clubbing, erythema nodosum, mouth ulcers, arthritis (ankylosing spondylitis; sacroiliitis), iritis/uveitis, pyoderma gangrenosum, liver disease
- Rectal examination is mandatory
Investigation
An AXR is necessary to look for toxic megacolon
Blood
- FBC, ESR, CRP
- U+E, LFTs, Bone, Glucose
- BC, Stool culture (+ C diff)
- ABG, if unwell
Other
- ECG (AF?)
- CXR (erect; perforation)
- AXR (toxic megacolon)
Key investigation
- AXR
Specialist investigation
- Sigmoidoscopy/colonoscopy (and biopsy)
- CT abdomen/MRI
- Barium enema
- CD: small bowel follow-through or small bowel MRI (± capsule endoscopy)
- Note: never do colonoscopy or Ba enema in acute attack, or to make diagnosis (need tissue)
Differential diagnoses
- Ischaemic colitis
- Acute gastroenteritis (especially C diff)
- Diverticulitis/Colonic carcinoma
- Parasites (amoebiasis)
- Radiation colitis
Treatment
Do NOT use anti-diarrhoeals
Treatment (first line)
Drugs
- IV HYDROCORTISONE 100 mg qds for 3 days only then review by gastroenterology (if not already involved), or
- PO PREDNISOLONE 30 mg od, if less severe
- Proctitis: MESALAZINE or steroid suppositories/enemas - eg PR PREDSOL/PREDFOAM od-bd for distal disease
- ± SC ENOXAPARIN 40 mg od, if not bleeding heavily
Procedures
- IV line + fluids, for rehydration and correction of electrolyte imbalance
- Patient can eat + drink if they wish
- Stool Chart
Prescribing issues
- Don't prescribe anti-diarrhoeals; enemas etc may be inappropriate if PR painful (ask)
Key management decisions
- Steroids/not
- Surgery/not
Stop
- Smoking (UC)
Treatment (second line)
Drugs
- Azathioprine/5-ASA (eg sulphasalazine, mesalazine)/ciclosporin/infliximab
- Methotrexate (CD)
Procedures
- Blood transfusion
- TPN
- If unwell, NBM (if ?operating soon), urinary catheter, CVP
- Surgery
Prescribing issues
- DO NOT use anti-diarrhoeals (eg codeine phosphate/ loperamide; may precipitate paralytic ileus, megacolon and proximal constipation)
- Only use anti-spasmodics, if necessary
Admit?
- Usually
Bed plan
- Gastroenterology Ward preferably
- Otherwise, Medical Admission Ward
- ± General surgery
- ± ITU
Referrals
Medical
- Gastroenterology
- ± General surgery
- ± ITU
Other
- IBD nurse
The Rest
If patient is relatively well, they may be managed as an outpatient. Ask gastroenterology first
Maxim
- "If you don't put your finger in it, you will put your foot in it"
Complications (and indications for surgery)
- Toxic megacolon
- Massive bleeding
- Perforation
- Failure to respond to medical Rx
- Carcinoma (especially UC)
Note: relapse and subsequent surgery common after discharge, but death uncommon
Follow-up
- Gastroenterology
- ± IBD nurse
- ± General surgery
Prognosis
- Markers of severe attack : >6 bloody stools/day, unwell, Hb <10, alb <30, toxic megacolon (colon >6cm), large PR bleed, fever, tachycardia, ESR >30 (Truelove and Witts Criteria in UC)
- If BO>8/day OR CRP>45 and BO>3-8/day, after 3 days of IV HYDROCORTISONE there is an 85% lilkelihood of patient requiring colectomy on same admission (Travis criteria)
- UC: 20% require surgery at some time; CD: 50-80%
Risk stratification (who can be managed as outpatient)
- If relatively well, and no tachycardia/fever, ESR/CRP not signficantly increased or Hb/albumin significantly decreased, can manage as OP
2° Prevention + Health promotion
- The effects of smoking, and stopping smoking on IBD are complicated. Either way, it is better not to smoke
Don't forget
- Rectal examination is mandatory
- Ask for gastroenterology and surgical support early
- Look at AXR (toxic megacolon)
- Start/increase steroids
Red flags
- Toxic megacolon