Inflammatory Bowel Disease (IBD)
Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. The two major types of inflammatory bowel disease are ulcerative colitis (UC), which is limited to the colon, and Crohn disease (CD), which can affect any segment of the gastrointestinal tract from the mouth to the anus, involves "skip lesions," and is transmural. There is a genetic predisposition for IBD, and patients with this condition are more prone to the development of malignancy.
The peak incidence is in the 15-30 year old age group. Consider IBD in patients presenting with abdominal pain, recurring or bloody diahrroea, weight loss and +/- lethargy.
Patients with established disease often have their own management plans and may have already failed these at home before presenting. Involve their treating physician early.
Abdominal pain – colicky, cramping
Commonly RLQ CD and periumbilically/LLQ in UC
Diarrhoea +/- mucous/blood
Weight loss or growth delay in children
Extraintestinal manifestations including ankylosing spondylitis, stomatitis, uveitis, iritis, arthritis – more common in children.
Toxic megacolon: a life-threatening complication, almost always involves the transverse colon and may present with ileus, peritonitis secondary to perforation, and sepsis
Mass in the right lower abdominal quadrant: May be present in CD
Perianal complications: May be observed in up to 90% of cases of CD.
Bloods - FBC, EUC, LFT, lactate
Imaging in the ED – consider erect CXR/AXR and +/- CT to look for obstruction, megacolon or perforation. (Be mindful of previous imaging and whether alternative imaging modalities are available such as USS or MRI as these patients are at risk of repeated radiation exposure)
Barium double-contrast enema radiographic studies
Colonoscopy, with biopsies of tissue/lesions
Upper gastrointestinal endoscopy
Markers of severity
Mild – Moderate
Max 40-60mg (or 1-2mg/kg) oral prednisolone daily until clinical response then decrease over 8-12 weeks until ceased.
Rehydrate with IV fluids
Electrolyte/blood replacement as required
Max 100mg (or 2-4mg/kg) IV hydrocortisone 6 hourly or methylprednisolone max 100mg (child 1mg/kg up to 50mg) IV daily
Antibiotics if sepsis present eg gentamicin, ceftriaxone, metronidazole
Surgical and gastroenterology consultation
Anti-TNF drugs eg infliximab, immunomodulator drugs eg azathioprine or 5-ASA drugs eg sulfasalazine may be used after discussion with gastroenterology
Toxic megacolon management.
Perianal fistulas/abscesses consult surgeons early
Antibiotic treatment includes oral metronidazole or ciprofloxacin.
Isolated proctitis – mesalazine rectal preparation plus 5-ASA oral prep
Add rectal steroid therapy if above ineffective eg hydrocortisone acetate 10% PR BD
Add oral prednisolone 40-60mg (1-2mg/kg) if above not adequate until a clinical response and then reduce over 8-12 weeks until ceased.
Further References and Resources
Diefenbach, K. and Breuer, C. (2006) 'Pediatric inflammatory bowel disease', World Journal of Gastroenterology, vol. 12, no. 20, pp. 3204-3212.
eTG - Therapeutic Guidelines: Crohn's Disease
eTG - Therapeutic Guidelines: Ulcerative Colitis
Murphy, S. (2008) 'Management of bloody diarrhoea in children in primary care', BMJ, vol. 336, pp. 1010-1015
Rowe, W. et al., 'Inflammatory Bowel Disease', 7 January 2015, Medscape.