IBD Acute Severe Flare Management (ACG 2020)

Algorithm Steps

1. ▶

   Start

   Acute Severe IBD Flare

   Known IBD with severe symptoms requiring hospitalization

   1. ●

      Action

      Assess Severity (Truelove-Witts)

      For UC - defines acute severe colitis

      • ≥6 bloody stools/day PLUS ≥1 of:
      • • HR >90 bpm
      • • Temp >37.8°C
      • • Hgb <10.5 g/dL
      • • ESR >30 mm/hr
      • Crohn's: use CDAI or Harvey-Bradshaw
      1. ●

         Action

         Initial Workup

         Rule out complications and infections

         • Stool C. diff, culture, ova & parasites
         • CMV PCR or tissue (if on immunosuppression)
         • CBC, CMP, CRP, ESR, albumin
         • AXR or CT if concern for toxic megacolon
         • Flexible sigmoidoscopy (limited, avoid perforation)
         1. ◆

            Decision

            Complications Present?

            Toxic megacolon, perforation, obstruction, abscess

            1. ⚠

               Warning

               ⚠️ Surgical Consult

               Immediate surgical evaluation needed

               • Toxic megacolon (colon >6cm)
               • Perforation/peritonitis
               • Uncontrolled hemorrhage
               • Abscess (Crohn's) - may need IR drainage
               1. ⚠

                  Warning

                  Colectomy

                  Subtotal colectomy with end ileostomy

                  • For UC: curative option
                  • Later IPAA (J-pouch) consideration
                  • Better outcomes with planned surgery vs. emergency
            2. ●

               Action

               IV Corticosteroids

               First-line for acute severe UC/Crohn's flare

               • Methylprednisolone 60mg IV daily
               • OR Hydrocortisone 100mg IV q8h
               • NPO or clear liquids initially
               • VTE prophylaxis (LMWH)
               • Avoid antidiarrheals/opioids
               1. ●

                  Action

                  Supportive Care

                  Concurrent management

                  • IV fluids, correct electrolytes
                  • Transfuse if Hgb <7-8
                  • Nutrition (enteral > TPN if possible)
                  • VTE prophylaxis essential
                  • Daily clinical and AXR assessment
                  1. ◆

                     Decision

                     Day 3 Assessment

                     Evaluate response to IV steroids

                     • Oxford criteria: stool frequency + CRP
                     • >8 stools/day OR 3-8 stools + CRP >45 = likely steroid failure
                     1. ●

                        Action

                        Steroid Response

                        Improving by day 3-5

                        • Continue IV steroids until stable
                        • Transition to PO prednisone
                        • Start/optimize maintenance therapy
                        • Taper steroids over 6-8 weeks
                        1. ✓

                           Outcome

                           Clinical Remission

                           Optimize maintenance therapy, close outpatient follow-up

                        2. ✓

                           Outcome

                           Maintenance Therapy

                           Infliximab, adalimumab, vedolizumab, ustekinumab, tofacitinib per disease

                     2. ⚠

                        Warning

                        Steroid-Refractory (No response by day 3-5)

                        Rescue therapy needed

                        • Infliximab 5-10 mg/kg IV (preferred)
                        • OR Cyclosporine 2-4 mg/kg/day IV
                        • OR Vedolizumab (slower onset)
                        • Check CMV, C. diff again
                        • Continue surgical evaluation
                        1. ◆

                           Decision

                           Response to Rescue Therapy?

                           Assess by day 5-7 of rescue therapy