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<< Management of Inflammatory Bowel Disease Flares in the Emergency Department (Pharmacology CME)

Treatment

The overarching goal in chronic IBD management is to induce and maintain disease remission. The severity and extent of all disease symptomatology—both gastrointestinal and extraintestinal—is used to guide therapy.

Acute Flares

A flare is recognized by the fact that a patient’s IBD symptoms, signs, and laboratory test results indicate a disease remission failure. Generally, this means that the patient experiencing a disease flare has some combination of increased diarrheal output, bloody stools, rectal urgency, abdominal cramps, bloating and/or pain, fever, fatigue, and weight loss. These physical manifestations of a flare are often accompanied by an elevated white blood cell count and an increase in ESR and/or CRP over baseline.

Fever can occur with flares due to an increased inflammatory response. It is also possible that fever may indicate a concomitant infection (which may have precipitated the flare) or a disease complication such as bowel perforation, toxic megacolon, or abscess formation.

The approach to CD treatment has changed substantially in recent years. Historically, clinical symptoms alone dictated treatment. Now it is understood that clinical symptoms correlate poorly with underlying inflammation, as demonstrated by all other methods of following the disease course (endoscopy, histology, imaging, and inflammatory biomarkers). If inflammation remains unchecked and untreated, disease progression leads to stricture, fistula, and abscess formation, with resultant hospitalization and surgery. “Deep remission” is the new CD treatment goal, a combination of symptom and endoscopic remission.51,52

Ideally, IBD flare management in the ED will be done in collaboration with a patient’s gastroenterologist (optimal) or primary care physician. Most IBD patients will not require emergent life-saving measures, but will benefit from intravenous fluids to treat dehydration, and symptom control for fever, nausea/vomiting, and pain. Corticosteroids are a mainstay of treatment for IBD flares.

There are no emergency medicine-based guidelines to direct IBD flare therapy, but the American Gastroenterological Association offers an evidence-based management scheme that is partially applicable to the ED. At the very least, it offers emergency clinicians an understanding of how gastroenterologists approach acute care of the IBD patient. It may also organize the approach to the IBD patient in the ED and provide rationale for the consultant’s recommendations. The full version of the American Gastroenterological Association management pathway can be found at: www.gastro.org/IBDcarepathway.

Surgical Emergencies and Surgical Treatment in Crohn Disease

It is estimated that up to 90% of CD patients will require surgery at some point in their disease course.53,54 This estimate is based on older literature, however, and this number may be decreasing. Medical management failure and disease complications (obstruction, fistula, mass, or abscess) are the 2 general indications for surgery in CD patients.53-55 Multiple surgical indications may be present simultaneously in CD patients.

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