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Inflammatory bowel disease
Acute severe colitis is a medical and surgical emergency from day one. Grade the flare with Truelove and Witts, exclude infection, start IV steroids and VTE prophylaxis, look for toxic megacolon, and reassess on day 3 to decide on rescue therapy or surgery. Built for revision, not live patient decisions.
Settle them, and check the basics
how severe?Red flags — what each should make you think
Steroids can mask peritonitis. A patient with acute severe colitis on high-dose steroids may have a perforation with surprisingly few signs. Examine twice a day, check daily bloods, and involve the surgeons from admission, not at the point of crisis.
Acute severe ulcerative colitis — first actions
- StIV hydrocortisone
- VTEVTE prophylaxis
- 🦠Stool tests
- AXRAbdominal X-ray
- IVFluids + electrolytes
- ☎Gastro + colorectal surgery
Understand the patient
UC vs Crohn'sTruelove & Witts — acute severe UC
- ≥6 bloody stools a day plus at least one of:
- HR above 90
- Temperature above 37.8°C
- Hb below 105 g/L
- ESR above 30 mm/h (or CRP above 30)
Day 3 assessment: more than 8 stools a day, or 3–8 stools with CRP above 45, predicts failure of steroids → discuss rescue therapy (infliximab or ciclosporin) or colectomy.
Avoid
- Opioids, antidiarrhoeals (loperamide), anticholinergics — risk of toxic megacolon
- NSAIDs
- Delaying surgical opinion
Crohn's presentations
- Obstruction (strictures) — see bowel obstruction page
- Abscess, fistula, perianal sepsis
- Flare with weight loss, pain, diarrhoea
- Steroids for flares; biologics via gastro; surgery for complications
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Severe colitis with distension, systemic toxicity, reducing stool frequency (not a good sign).
AXR: transverse colon over 5.5 cm.
Urgent colorectal surgery; IV steroids, fluids, correct electrolytes; stop opioids/anticholinergics. Colectomy if no rapid improvement.
Sudden pain, peritonism, tachycardia — signs may be blunted by steroids.
Erect CXR / CT.
Emergency surgery.
Recent antibiotics, hospital, travel, contacts.
Stool culture, C. difficile toxin; CMV on biopsy if steroid-refractory.
Treat the infection; it can coexist with a flare.
Fever, localised pain, mass, perianal swelling or discharge.
CT abdomen, MRI pelvis.
Antibiotics, drainage (radiological or surgical), avoid steroids until sepsis controlled.
Investigate — what to order, when, and what it tells you
test with a question in mindBloods
Stool
Imaging
Endoscopy
How the plan comes together
disposition · handovergastro ward (joint care)
Acute severe UC on IV steroids, day-3 review, rescue therapy or surgery decisions with the patient.
surgery / HDU
Toxic megacolon, perforation, massive bleeding, failed rescue therapy.
Hand over: stool frequency, CRP trend, day of steroids, AXR findings, surgical review.
Grade it, exclude infection, give IV steroids and LMWH, keep opioids away, and make the day-3 decision on time. Delaying surgery in failing colitis is what harms patients. Nicely done getting here.
Clerking template
copy or downloadInflammatory bowel disease — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for an acute IBD flare?
- ≥6 bloody stools/day + systemic upset — think acute severe colitis
- Colon over 5.5 cm on AXR — think toxic megacolon
- Peritonism, sudden pain — think perforation
- Recent antibiotics / hospital — think C. difficile
- Crohn's + fever + mass — think abscess
- Perianal pain/swelling — think perianal sepsis
What is the initial management of an acute IBD flare?
- IV hydrocortisone — 100 mg 6-hourly (or IV methylprednisolone 60 mg daily)
- VTE prophylaxis — LMWH — even with rectal bleeding (high clot risk)
- Stool tests — culture, C. difficile toxin
- Abdominal X-ray — colonic dilatation, mucosal islands
- Fluids + electrolytes — correct K⁺ and Mg²⁺ (low K⁺ promotes megacolon)
- Gastro + colorectal surgery — joint care from admission
Always alongside senior support and your local guideline.
What diagnoses must you not miss in an acute IBD flare?
- Toxic megacolon — colon over 5.5 cm
- Perforation — peritonism (masked)
- Infective colitis / C. difficile — always exclude
- Crohn's abscess / perianal sepsis — fever · mass
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for an acute IBD flare?
- Bloods — FBC, CRP, U&E, LFT, albumin, Mg.
- Stool — Culture, C. difficile toxin, faecal calprotectin (outpatient).
- Imaging — Megacolon, extent.
- Endoscopy — Unprepared, gentle — confirms severity, biopsies for CMV.
Admit or discharge: how is the plan decided for an acute IBD flare?
- Gastro ward (joint care) — Acute severe UC on IV steroids, day-3 review, rescue therapy or surgery decisions with the patient.
- Surgery / hdu — Toxic megacolon, perforation, massive bleeding, failed rescue therapy.
Is there a clerking template for an acute IBD flare?
Yes — there is a free clerking template for an acute IBD flare on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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