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Inflammatory Bowel Disease

Francesca Raffa


  • Ulcerative colitis (UC): colon only (can have backwash ileitis); contiguous lesions; mucosal inflammation
  • Crohn’s disease (CD): any part of the GI tract; “skip lesions”; transmural inflammation
  • Important historical considerations to include in your documentation and presentation:
    • Location of disease (CD: LB/SB, LB only, SB only; UC: proctitis, left-sided or pancolitis)
    • Complications: Fistulizing, strictures, perianal, prior surgeries, current IBD treatment
    • Include last endoscopies and imaging findings; current and prior IBD treatment and reason for transition (SEs, failure), primary IBD provider


  • UC: frequent diarrhea (often bloody), tenesmus, urgency, abdominal pain; may have fever, malaise, and weight loss
    • Complications: severe bleeding/anemia, fulminant colitis, toxic megacolon
  • CD: abdominal pain, nausea/vomiting, fever, malaise, weight loss; May also have diarrhea (± bloody depending on CD location)
    • Complications: fistulas (entero-enteric, entero-vesicular, entero-cutaneous, rectovaginal, perianal, retroperitoneal), abscesses, strictures, obstruction
  • Extra-intestinal (EI): arthritis, sacro-iliitis, uveitis, episcleritis, aphthous ulcers, erythema nodosum, pyoderma gangrenosum, PSC (esp. UC), nephrolithiasis, thromboembolism


  • CBC w/diff, CMP, CRP, ESR, ± blood cultures
  • If diarrhea: GI Pathogen panel and C. diff
  • If anemic: obtain iron studies and type & screen
  • If weight loss or concern for malnutrition: albumin, pre-albumin, Vitamin D, B12, folate
  • Imaging:
    • CT Enterography (oral contrast) preferred in CD, for luminal/extra-luminal complications
    • How to order CTE: “CT abdomen pelvis enterography”, order barium (Volumen) 0.1% oral suspension x2, 1st dose to be given by nurse 60 min before study, 2nd study to be given 30 min before (nurse should be in contact with CT tech)


  • Acute Flare
  • Pain control: usually a major component of hospital course
    • Avoid NSAIDs, oral pain medications are preferred
    • If pain is difficult to control, consider Acute Pain Service consult
    • Narcotics and Imodium are contraindicated in toxic megacolon
  • Antibiotics: appropriately treat infections (intra-abdominal or perianal abscess) with antibiotics (consider prior culture data, often use cipro/flagyl)
  • VTE Prophylaxis: All IBD patients, even if having blood in stool (unless requiring transfusion) as they are at much higher risk of VTE
  • Nutrition: Nutrition consult for all IBD patients; For severe malnutrition or if prolonged bowel rest is needed, TPN is sometimes initiated
  • Anemia: Ferritin \<100 or iron sat \<20 with ferritin \<300, consider iron infusions (if no bacteremia) or transfuse for severe anemia
  • Smoking Cessation (esp. with CD): discuss smoking cessation & consult tobacco cessation
  • Consult Colorectal Surgery (not EGS): SBO, toxic megacolon, bowel perforation, peritonitis
  • Immunosuppression: (Infections must be ruled out and/or treated before starting)
  • Steroids:
    • Methylprednisolone (Solumedrol); often 20 mg BID for three days
    • Transition to oral (40 mg prednisone daily) once clinically improved/tolerating PO; typically prescribe a prolonged taper on discharge (often down by 5 mg every week)
    • If severe proctitis: consider rectal steroids (hydrocortisone enema/foam)
  • If lack of response to steroids: additional medical therapy (biologics), bowel rest with TPN, or surgical intervention
    • Infliximab (Inflectra) is available at VUMC
    • If patient fails to respond to steroids, should consider possibility of CMV colitis (usually evaluated by biopsy on flex sig or colonoscopy)
    • Prior to initiating a biologic, all patients must have the following negative studies within the last year: Quantiferon Gold and CXR, Hepatitis B serologies, HIV, urine histoplasma Ag (some providers)