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Emergency And Acute Medicine – Inflammatory Bowel Disease
Basics
Description Inflammatory bowel disease (IBD) consists of idiopathic, chronic inflammatory disorders of the gastrointestinal tract with frequent extraintestinal involvement. It includes ulcerative colitis (UC), Crohn disease, and intermediate forms. Disease may present as new onset or as an acute exacerbation. Crohn disease often presents subtly and requires a high index of suspicion. In UC, inflammation is continuous, begins in the rectum, and is limited to the colon and submucosa. Crohn disease may affect any region from mouth to anus, is discontinuous, and involves transmural inflammation. Both conditions are associated with an increased risk of colon cancer after more than 10 years of disease. Age distribution is bimodal, with peaks in early adulthood and around 60 years of age. Pediatric cases may present early in life, often with prominent extraintestinal features.
Etiology
The cause is unknown. IBD is multifactorial, involving genetic susceptibility, environmental influences, and dysregulated immune responses. Family history is common. No definitive infectious cause has been identified, though psychosocial stress may exacerbate symptoms.
Diagnosis
Signs and symptoms Crohn disease may manifest as inflammatory, fibrostenotic, or fistulizing disease. Ulcerative colitis ranges from mild to fulminant colitis. Constitutional symptoms include fever, fatigue, night sweats, and weight loss, particularly in Crohn disease, with growth or pubertal delay in children. Gastrointestinal manifestations include abdominal pain, diarrhea, and bleeding. Crohn disease pain is often episodic and periumbilical or right lower quadrant, while UC pain is more generalized and often associated with defecation. Diarrhea in UC is typically bloody with mucus, urgency, and tenesmus. Extraintestinal manifestations include arthritis, uveitis, episcleritis, aphthous ulcers, erythema nodosum, and pyoderma gangrenosum. Perianal disease such as fissures, abscesses, and fistulas is characteristic of Crohn disease and absent in UC.
Essential workup
IBD should be considered in patients with chronic diarrhea, abdominal pain, weight loss, anemia, or extraintestinal inflammatory findings, especially with recurrent or unexplained presentations.
Diagnosis tests and interpretation
Lab No single diagnostic test exists. Common findings include anemia, elevated ESR, electrolyte abnormalities, and inflammatory markers. Stool studies should exclude infectious etiologies including Clostridioides difficile.
Imaging Upright abdominal and chest radiographs assess for toxic megacolon, obstruction, or perforation. CT or MRI of the abdomen helps identify abscesses, inflammatory masses, and complications, with MRI preferred when available to limit radiation exposure. Colonoscopy with biopsy confirms diagnosis but should be deferred in severe disease due to perforation risk.
Differential diagnosis
Infectious colitis, pseudomembranous colitis, appendicitis, diverticulitis, ischemic colitis, colorectal cancer, functional bowel disease, sexually transmitted proctitis, HIV, vasculitis, and lymphoma.
Treatment
Initial stabilization Provide IV isotonic fluids for dehydration and transfuse if there is significant blood loss.
Emergency department management Insert nasogastric tube if obstruction or toxic dilation is suspected. Administer broad-spectrum antibiotics in fulminant disease, suspected perforation, or sepsis. Stress-dose steroids may be required in patients recently on chronic steroids. Surgical consultation is mandatory for perforation, uncontrolled hemorrhage, obstruction, or toxic megacolon. Medical therapy is generally continued or resumed rather than initiated in the ED unless previously established, with gastroenterology consultation recommended.
Medication
Therapies depend on disease severity and prior diagnosis and may include aminosalicylates, corticosteroids, antibiotics such as metronidazole or ciprofloxacin for Crohn disease, and immunomodulators or biologics under specialist guidance.
Follow-up and disposition
Admission criteria Indications include perforation, obstruction, toxic megacolon, massive bleeding, severe pain, dehydration, electrolyte imbalance, high fever, or severe flare requiring intensive therapy.
Discharge criteria Mild symptoms without toxicity, obstruction, significant bleeding, or dehydration, with reliable follow-up and established care.
Follow-up recommendations Gastroenterology follow-up is essential, with surgical consultation for complications or refractory disease.
Pearls and pitfalls
Always exclude toxic megacolon in severe flares. Avoid antidiarrheal agents in severe ulcerative colitis. Consider Crohn disease in children with growth delay or perianal disease. Always rule out C. difficile during disease exacerbations.
Basics
Description Inflammatory bowel disease (IBD) consists of idiopathic, chronic inflammatory disorders of the gastrointestinal tract with frequent extraintestinal involvement. It includes ulcerative colitis (UC), Crohn disease, and intermediate forms. Disease may present as new onset or as an acute exacerbation. Crohn disease often presents subtly and requires a high index of suspicion. In UC, inflammation is continuous, begins in the rectum, and is limited to the colon and submucosa. Crohn disease may affect any region from mouth to anus, is discontinuous, and involves transmural inflammation. Both conditions are associated with an increased risk of colon cancer after more than 10 years of disease. Age distribution is bimodal, with peaks in early adulthood and around 60 years of age. Pediatric cases may present early in life, often with prominent extraintestinal features.
Etiology
The cause is unknown. IBD is multifactorial, involving genetic susceptibility, environmental influences, and dysregulated immune responses. Family history is common. No definitive infectious cause has been identified, though psychosocial stress may exacerbate symptoms.
Diagnosis
Signs and symptoms Crohn disease may manifest as inflammatory, fibrostenotic, or fistulizing disease. Ulcerative colitis ranges from mild to fulminant colitis. Constitutional symptoms include fever, fatigue, night sweats, and weight loss, particularly in Crohn disease, with growth or pubertal delay in children. Gastrointestinal manifestations include abdominal pain, diarrhea, and bleeding. Crohn disease pain is often episodic and periumbilical or right lower quadrant, while UC pain is more generalized and often associated with defecation. Diarrhea in UC is typically bloody with mucus, urgency, and tenesmus. Extraintestinal manifestations include arthritis, uveitis, episcleritis, aphthous ulcers, erythema nodosum, and pyoderma gangrenosum. Perianal disease such as fissures, abscesses, and fistulas is characteristic of Crohn disease and absent in UC.
Essential workup
IBD should be considered in patients with chronic diarrhea, abdominal pain, weight loss, anemia, or extraintestinal inflammatory findings, especially with recurrent or unexplained presentations.
Diagnosis tests and interpretation
Lab No single diagnostic test exists. Common findings include anemia, elevated ESR, electrolyte abnormalities, and inflammatory markers. Stool studies should exclude infectious etiologies including Clostridioides difficile.
Imaging Upright abdominal and chest radiographs assess for toxic megacolon, obstruction, or perforation. CT or MRI of the abdomen helps identify abscesses, inflammatory masses, and complications, with MRI preferred when available to limit radiation exposure. Colonoscopy with biopsy confirms diagnosis but should be deferred in severe disease due to perforation risk.
Differential diagnosis
Infectious colitis, pseudomembranous colitis, appendicitis, diverticulitis, ischemic colitis, colorectal cancer, functional bowel disease, sexually transmitted proctitis, HIV, vasculitis, and lymphoma.
Treatment
Initial stabilization Provide IV isotonic fluids for dehydration and transfuse if there is significant blood loss.
Emergency department management Insert nasogastric tube if obstruction or toxic dilation is suspected. Administer broad-spectrum antibiotics in fulminant disease, suspected perforation, or sepsis. Stress-dose steroids may be required in patients recently on chronic steroids. Surgical consultation is mandatory for perforation, uncontrolled hemorrhage, obstruction, or toxic megacolon. Medical therapy is generally continued or resumed rather than initiated in the ED unless previously established, with gastroenterology consultation recommended.
Medication
Therapies depend on disease severity and prior diagnosis and may include aminosalicylates, corticosteroids, antibiotics such as metronidazole or ciprofloxacin for Crohn disease, and immunomodulators or biologics under specialist guidance.
Follow-up and disposition
Admission criteria Indications include perforation, obstruction, toxic megacolon, massive bleeding, severe pain, dehydration, electrolyte imbalance, high fever, or severe flare requiring intensive therapy.
Discharge criteria Mild symptoms without toxicity, obstruction, significant bleeding, or dehydration, with reliable follow-up and established care.
Follow-up recommendations Gastroenterology follow-up is essential, with surgical consultation for complications or refractory disease.
Pearls and pitfalls
Always exclude toxic megacolon in severe flares. Avoid antidiarrheal agents in severe ulcerative colitis. Consider Crohn disease in children with growth delay or perianal disease. Always rule out C. difficile during disease exacerbations.
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