Symptoms and signs

• Severe diarrhoea, tenesmus
• Abdominal pain
• Anorexia, weight loss
• Malaise
• Variable amount of blood in stool
• Dehydration
• Tachycardia
• Fever
• Anaemia

Life-threatening features

• Severe sepsis/septic shock
• Toxic dilatation of colon
• Perforation of colon
• Profound electrolyte disturbance
• Massive haemorrhage
• Obvious weight loss
• Secondary multi-organ failure

Investigations

• FBC
• U&E
• LFT
• CRP
• Blood glucose
• Abdominal X-ray
• Erect chest X-ray – look for gas under diaphragm
• Stool culture (Salmonella, Shigella, Campylobacter), Clostridium difficile toxin
• Crossmatch: group and save
• Arterial blood gases

Differential diagnosis

• Bacterial and amoebic colitis (history of travel)
• Pseudomembranous colitis (history of antimicrobial use)
• Diverticular disease
• Ischaemic colitis
• Bowel cancer
• Abdominal lymphoma
• Radiation colitis
• Ileocaecal TB

Logistics

• If needed, contact on-call consultant gastroenterologist
• In patients with life-threatening features inform duty surgical team
• Barrier nurse
• inflammatory bowel disease can at first be indistinguishable from infective diarrhoea
• Admit to GI ward

Drugs and fluid

• Establish IV access and correct dehydration/electrolyte disturbance
• If Hb <80 g/L, give blood transfusion
  • 4 units plus an extra unit for each g/L below 80
• Hydrocortisone 200 mg 8-hrly by slow IV injection over 1 min
• Ensure all patients receive prophylactic dalteparin 5000 units once daily
• If not improving either clinically or biochemically after 48 hr, consider escalation therapy with:
  • either ciclosporin IV (unlicensed and rarely used) or infliximab IV only after discussion with consultant gastroenterologist or via a consensus opinion in IBD MDT (contact IBD Nurses for further information)
• If still no improvement by day 5, consider surgical opinion

• Once infective element has been excluded, relax barrier nursing restrictions
• Ensure patient discussed with consultant gastroenterologist

If improving

• Substitute prednisolone (not enteric coated) 40 mg oral daily in place of hydrocortisone
• taper dose by 5mg every week
• co-prescribe calcium and vitamin D (e.g. Adcal D3® 2 tablets daily) whilst on prednisolone
• Start restricted oral feeding. Seek dietetic opinion
• Give mesalazine (Octasa^® MR) 800 mg oral 8-hrly
• For distal disease, consider hydrocortisone foam enema 10% 12–24 hrly for 2–3 weeks
• If extent and severity of inflammation not apparent from supine plain abdominal X-ray
• consult with consultant gastroenterologist to plan colonoscopy in convalescent phase

If not improving

• If no improvement after 48 hr, consider escalation therapy with:
• either IV ciclosporin (unlicensed) or infliximab
• only after discussion with a consultant gastroenterologist
• If still no improvement by day 5, consider surgery

2-hrly

• Temperature
• Pulse
• BP
• Respiration

Twice daily

• Abdominal examination
• look for local peritonism and check bowel sounds
• Measure abdominal girth

Daily

• FBC, U&E, stool culture
• Abdominal X-ray
• look for free abdominal gas or colonic dilatation >6 cm
• Count stools and inspect for blood

Alternate days

• Erect chest X-ray: look for gas under diaphragm

Plan home treatment regimen

• Prednisolone (not enteric coated)
• taper daily dosage by 5 mg each week to zero or previous maintenance dosage
• co-prescribe calcium and vitamin D (e.g. Adcal D3® 2 tablets daily) whilst on prednisolone
• If distal disease, hydrocortisone foam enema 10% 12–24 hrly
• Mesalazine (Octasa^® MR), usually 800 mg 8-hrly but higher doses (up to 4.8 g/day) can be used if needed
• Nutritional support, as advised by dietitian

Follow-up

• If outpatient colonoscopy not already performed, arrange in consultation with consultant gastroenterologist
• Arrange follow-up in gastrointestinal outpatient clinic after 4 weeks
• Give patient information literature and encourage membership of Crohn's and Colitis UK
• Inform IBD Nurses of admission, especially if new diagnosis