Please note: this guideline has exceeded its review date and is currently under review by specialists. Exercise caution in the use of the clinical guideline.

Management of Severe Exacerbation of Inflammatory Bowel Disease

Assessment / monitoring

On admission

  • Stool culture and Clostridium difficile toxin.
  • Stool chart (kept by nursing staff).
  • BP / pulse / temperature - frequency depends on initial findings.
  • Bloods – FBC; CRP or ESR; U&Es; LFTs; blood cultures.
  • X-ray – plain film of abdomen.
  • If features suggesting severe disease present, seek immediate senior review. Features of severe disease are:
    • >6 bloody stools per day and systemic toxicity with at least one of:
    • temperature >37.8°C
    • pulse >90bpm
    • haemoglobin <105g/L or C-reactive protein >30mg/L
  • Unprepared sigmoidoscopy in new patient.

General management and treatment options

  • Avoid anti-diarrhoeal agents
  • Give IV fluids
  • Give methylprednisolone sodium succinate IV 30mg infusion every 12 hours
  • Give low residue diet / oral fluids
  • Give high calorie supplements
  • If Hb below normal – replace deficient haematinics and consult with the gastroenterology team to advise on the need for transfusion or parenteral iron infusion
  • High risk of venous thromboembolism – give thromboprophylaxis (unless contraindicated)
  • Involve gastroenterologist / gastrointestinal surgeon

Note: Caution with:

  • Narcotics*
  • Antispasmodics*
  • Hypokalaemia
  • Barium enema

Discuss with radiologist / gastroenterologist.

*Patient with abdominal pain must be seen and assessed before prescribing analgesia.

Ongoing management

  • Monitor Hb, WCC, U&Es, CRP daily
  • Daily abdominal film whilst on IV steroid therapy and arrange surgical review if transverse or ascending colon diameter >6cm.
  • Light diet
  • A CRP >45 or the stool frequency >8 at day 3 are bad prognostic signs and senior review and/or surgical review should be undertaken immediately.

Drug treatment after 5–7 days

  • Change IV methylprednisolone to: prednisolone oral 40mg each day. Reduce no faster than by 5mg every 5–7 days. Normally there is gradual reduction over a 4–8 week period if CRP and stool frequency falling.

N.B. HEPMA prescribing protocol ('prednisolone - gastroenterology reducing regimen') available under the protocol tab by searching for prednisolone.

  • If ulcerative colitis add mesalazine oral (seek specialist advice if unsure):
      • Salofalk® MR granules 1.5-3g once daily or in three divided doses (or Salofalk® tablet 1.5-3g daily in three divided doses).

    Alternatives are:

    • Pentasa® MR tablets / sachets 2–4g once daily or
    • Octasa® MR tablets 2.4-4.8g per day in divided doses
  • Rectal preparations (e.g. mesalazine 1g suppositories / enemas) may be useful in proctitis, left sided disease and Crohn's disease of the rectum and anus. Seek specialist advice.

Discharge

Normally discharged when:

  • Non-toxic
  • Stool frequency decreased, consistency increased and macroscopic blood decreased
  • Lab parameters stable
  • Follow-up OPD appointment made

 

Guideline reviewed June 2022
Page updated November 2025



;