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IBD Acute Severe Flare Management (ACG 2020)

IBD Acute Severe Flare Management (ACG 2020): Acute Severe IBD Flare → Assess Severity (Truelove-Witts) → Initial Workup → Complications Present? → ⚠️ S...

Pathway Overview

14 steps

Algorithm Steps

14 total

  1. 01Start

    Acute Severe IBD Flare

    Known IBD with severe symptoms requiring hospitalization

  2. 02Action

    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
  3. 03Action

    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)
  4. 04Decision

    Complications Present?

    Toxic megacolon, perforation, obstruction, abscess

  5. 05Warning

    ⚠️ Surgical Consult

    Immediate surgical evaluation needed

    • Toxic megacolon (colon >6cm)
    • Perforation/peritonitis
    • Uncontrolled hemorrhage
    • Abscess (Crohn's) - may need IR drainage
  6. 06Warning

    Colectomy

    Subtotal colectomy with end ileostomy

    • For UC: curative option
    • Later IPAA (J-pouch) consideration
    • Better outcomes with planned surgery vs. emergency
  7. 07Action

    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
  8. 08Action

    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
  9. 09Decision

    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
  10. 10Action

    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
  11. 11Outcome

    Clinical Remission

    Optimize maintenance therapy, close outpatient follow-up

  12. 12Outcome

    Maintenance Therapy

    Infliximab, adalimumab, vedolizumab, ustekinumab, tofacitinib per disease

  13. 13Warning

    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
  14. 14Decision

    Response to Rescue Therapy?

    Assess by day 5-7 of rescue therapy

  15. Path rejoins step 12Shared downstream outcome
  16. Path rejoins step 06Shared downstream outcome
  17. Path rejoins step 09Shared downstream outcome

Guideline Source

ACG Clinical Guidelines: Ulcerative Colitis in Adults (2019) & Crohn's Disease (2018)

DOI: 10.14309/ajg.0000000000000152View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Primarily addresses acute severe UC (Truelove-Witts criteria)
  • Crohn's flares may have different triggers (abscess, stricture)
  • Biologic choice evolving rapidly
  • CMV reactivation testing important in refractory cases
  • Surgical timing requires multidisciplinary input

Applicable Regions

USEUGlobal

EU: ECCO guidelines are similar

US: ACG guidelines current standard

Version 1Next review: 2027-01-01

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Frequently Asked Questions

What is the IBD Acute Severe Flare Management (ACG 2020)?

The IBD Acute Severe Flare Management (ACG 2020) is a emergency clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on ACG Clinical Guidelines: Ulcerative Colitis in Adults (2019) & Crohn's Disease (2018).

What guideline is the IBD Acute Severe Flare Management (ACG 2020) based on?

This algorithm is based on ACG Clinical Guidelines: Ulcerative Colitis in Adults (2019) & Crohn's Disease (2018) (DOI: 10.14309/ajg.0000000000000152).

What are the limitations of the IBD Acute Severe Flare Management (ACG 2020)?

Known limitations include: Primarily addresses acute severe UC (Truelove-Witts criteria); Crohn's flares may have different triggers (abscess, stricture); Biologic choice evolving rapidly; CMV reactivation testing important in refractory cases; Surgical timing requires multidisciplinary input. Individual patient factors may require deviation from these recommendations.

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