Inflammatory Bowel Disease, Emergency Medicine

Basics

Description

Idiopathic, chronic inflammatory diseases of intestines, which can involve extraintestinal sites as well.
Differentiation between ulcerative colitis (UC) and Crohns is not always clear; intermediate forms of inflammatory bowel disease (IBD) exist.
May present as initial onset of disease or exacerbation of existing disease.
Maintain high index of suspicion owing to frequent, subtle presentation of Crohn's disease.
Pediatric considerations:
- Can occur in 1st few years of life.
- Extraintestinal manifestations may predominate.
Differences between Crohn's and UC:
- Rectum almost always involved in UC with continuous inflammation proximally.
- Small intestine is not involved in UC.
- Crohn's can occur anywhere from mouth to anus, often with normal GI tract segments between affected areas.
- Crohn's involves transmural inflammation, whereas UC is confined to submucosa.
Similarities between Crohn's and UC:
- Higher rate of colon cancer with disease >10 yr.
- Bimodal age distribution, with early peak between teens and early 30s and 2nd peak about age 60 yr.
Crohn's disease clinical pattern:
- Ileocecal: ~40%
- Small bowel: ~30%
- Colon: ~25%
- Other: ~5%
UC clinical pattern on presentation:
- Pancolitis: 30%:
  - Most severe clinical course
Proctitis or proctosigmoiditis: 30%:
- Relatively mild clinical course
Left-sided colitis (up to splenic flexure): 40%:
- Moderate clinical course

Etiology

Unknown
Crohns disease and UC are separate entities with common genetic predisposition.
A positive family history is very common.
Multifactorial origin involving interplay among the following factors:
- Genetic
- Environmental
- Immune
Pathogenesis:
- Gut wall becomes unable to downregulate its immune responses, ultimately resulting in chronic inflammation.
There is no definitive evidence for the etiologic role of infectious agents.
Psychogenic factors may play a role in some symptomatic exacerbations.

Diagnosis

Signs and Symptoms

Crohns disease can present with any clinical correlates of chronic inflammatory, fibrostenotic, or fistualizing illness.
UC may begin subtly or as catastrophic illness.
Constitutional, GI, and extraintestinal manifestations are common with both Crohn's and UC.

History

Constitutional:
- Crohns:
  - Low-grade fever
  - Night sweats
  - Weight loss
  - Fatigue
  - Pediatric: Growth or pubertal delay
- UC:
  - Fever usually only in fulminant disease
  - Weight loss/fatigue
GI:
- Abdominal pain/tenderness-Crohn's disease:
  - Episodic
  - Periumbilical; may localize to right lower quadrant (RLQ) with ileal disease
  - Generalized with more diffuse intestinal involvement
  - Can localize to area of intra-abdominal abscesses or fistulous involvement
  - Tenderness and distension suggest obstruction or toxic megacolon
- Abdominal pain/tenderness-UC:
  - More generalized than Crohn's disease
  - Often limited to predefecatory period
  - Tenderness with distension-suspect toxic dilation
Stool:
- Crohn's disease:
  - Mild, loose stool, rarely >5/day
  - ~50% bloody
- UC:
  - Diarrhea is variable, can be severe.
  - Vast majority are bloody, sometimes with severe hemorrhage.
  - Mucus
  - Tenesmus and urgency are common.
Nausea/vomiting:
- Crohn's disease:
  - Obstruction common with ileocolonic disease
- UC:
  - Obstruction rare
  - Diminished bowel sounds with toxic dilation
Liver:
- Sclerosing cholangitis can be seen.
- Cholelithiasis can be seen in 35-60% of Crohn's.
Renal:
- Nephrolithiasis
- Obstructive hydronephrosis
Musculoskeletal:
- Peripheral arthritis/arthralgias-follows disease activity.
- Pediatric-may be confused with juvenile rheumatoid arthritis, idiopathic growth failure, anorexia nervosa.

Physical Exam

Perianal:
- Crohns disease:
  - Perianal abscesses
  - Fissures-characteristically painless
  - Fistulas-seen in up to 50% of patients with colonic disease.
  - May present prior to other manifestations.
- UC:
  - No perianal involvement
RLQ pain/mass often mistaken for appendicitis.
Severe toxicity/abdominal pain-must exclude toxic megacolon.
Extraintestinal:
- Eye:
  - Uveitis
  - Episcleritis
  - Keratitis
- Oral:
  - Aphthous stomatitis
- Dermatologic:
  - Erythema nodosum
  - Pyoderma gangrenosum

Essential Workup

May present as initial onset of disease or exacerbation of existing disease.
Maintain high index of suspicion because of subtle presentation of Crohns disease.

Diagnosis Tests & Interpretation

Lab

Nothing diagnostic
CBC:
- Anemia secondary to chronic or acute blood loss
Electrolytes, BUN/creatinine, glucose
Stool exam:
- Occult blood
- Clostridium difficile
- Fecal leukocytes may be present.
- O & P and culture to rule out infectious cause of enteritis
ESR is always elevated.
Newer, investigational, serologic tests may have use as adjunctive diagnostic aids, screening tests, or predictors in therapy.

Imaging

Lifetime radiation dose is cumulative and IBD patients have repeated exposure; consider MRI when available.
Upright chest and abdominal radiographs for:
- Toxic megacolon (>6 cm dilation)
- Obstruction
- Air in wall of colon (may indicate impending perforation)
- Perforation-subdiaphragmatic air or free air outlining liver or gall bladder
CT abdomen/MRI:
- Distinguish abscess from localized inflammatory mass in Crohns.
Colonoscopy with biopsy can confirm diagnosis of UC or Crohn's:
- Can be withheld with severe symptoms owing to perforation risk.
Contrast imaging of small bowel, especially terminal ileum, may confirm diagnosis of Crohn's.
MRI can be useful in Crohn's perianal disease and avoids ionizing radiation.

Differential Diagnosis

Infectious enteritis
Pseudomembranous colitis (C. difficile)
Appendicitis
Diverticulitis
Diverticulosis
Functional bowel disease
Lymphoma involving bowel
Ischemic colitis
Gonococcal or chlamydial proctitis
HIV
Colon cancer
Vasculitis
Amyloidosis

Treatment

Pre-Hospital

Vital sign stabilization as per BLS

Initial Stabilization/Therapy

IV 0.9% NS volume replacement if dehydrated
Transfusion if significant blood loss

Ed Treatment/Procedures

Nasogastric (NG) suction if obstruction or toxic dilation suspected
Broad-spectrum antibiotics for fulminant UC or suspected perforation
Consider steroid replacement if stress doses are required for those recently on oral steroids.
Surgical evaluation indications:
- Free perforation
- Intestinal obstruction
- Massive, unresponsive hemorrhage
- Toxic dilation:
  - Not an absolute indication for surgery
  - Intensive medical management with small bowel decompression and close radiographic monitoring and surgical consultation
Walled-off perforation with abscess:
- Usually not an indication for emergent surgery
- Careful observation for peritonitis
Medical therapy:
- Treatment is usually not initiated unless diagnosis is already established.
- Refill or restart medications in patient with known disease.
- ED-prescribed medical regimen should be individualized, and consultation with gastroenterologist strongly recommended:
  - Aminosalicylate (sulfasalazine/mesalamine) in mild to moderate case.
  - Antidiarrheal agent (diphenoxylate) is used-but withhold if severe disease or suspect toxic megacolon.
  - Steroid (prednisone, budesonide or hydrocortisone enema, ACTH) is used for moderate to severe disease.
  - Antibiotics (metronidazole and/or ciprofloxacin) aid in treatment of Crohns with colon/perineal involvement.
  - Immunosuppressive agents (azathioprine, methotrexate) are used in severe disease.
  - Monoclonal antibodies neutralize cytokine tumor necrosis factor (TNF)-Î± and inhibit binding to TNF-Î± receptors (infliximab [Remicade]). Used as parenteral therapy in disease unresponsive to other modalities. Not an ED drug, but be aware of potential severe adverse reactions, infusion reactions, autoimmune diseases, and infections.

If nonaccidental trauma is suspected, prompt referral to appropriate child protective agencies is required along with medical treatment.

Medication

Ciprofloxacin: 500 mg (peds: 10-20 mg/kg q12) PO q12h
Hydrocortisone enema: 60 mg per rectum
Mesalamine enemas: 1-4 g retention enema-retain overnight. Adult.
Mesalamine suppository: 500 mg per rectum BID. Adult.
Mesalamine tablets:
- Asacol 800 mg PO TID
- Pentasa 1,000 mg PO QID
Methylprednisolone: 125-250 mg IV load (peds: 2 mg/kg IV load, maintenance as adult), then 0.5-1 mg/kg/dose q6h for 5 days
Metronidazole: 250-500 mg (peds: 30 mg/kg/24h) PO TID
Prednisone: 40-60 mg (peds: 1-2 mg/kg) PO daily
Sulfasalazine (Azulfidine): 500 mg (peds: 30 mg/kg) PO QID

Follow-Up

Disposition

Admission Criteria

Surgical indication:
- Massive, unresponsive hemorrhage
- Perforation
- Toxic dilation
- Obstruction
Severe flare-up:
- Electrolyte imbalance
- Severe dehydration
- Severe pain
- High fever
- Significant bleeding

Discharge Criteria

Initial presentation of diarrhea, mild pain, without toxicity, with close follow-up
Mild to moderate exacerbation of known disease without obstruction, severe bleeding, severe pain, dehydration, with close follow-up, on renewed therapy or with addition of steroid

Issues for Referral
Extraintestinal manifestations

Ocular
Dermatologic

Followup Recommendations

Gastroenterologist or primary care as managing physician with surgical consultation as indicated

Pearls and Pitfalls

With severe flare, rule out toxic megacolon.
Consider Crohns in children with growth/puberty delay.
Consider Crohn's with perianal disease.
Rule out C. difficile with flares; the incidence of C. difficile complicating IBD is increasing.
Avoid antidiarrheals/spasmodic in severe UC.

Additional Reading

Ananthakrishnan AN, Issa M, Binion DG. Clostridium difficile and inflammatory bowel disease. Gastroenterol Clin North Am. 2009;38(4):711-728.
Sandborn WJ. New concepts in anti-tumor necrosis factor therapy for inflammatory bowel disease. Rev Gastroenterol Disord. 2005;5(1):10-18.
Sauer CG, Kugathasan S. Pediatric inflammatory bowel disease: Highlighting pediatric differences in IBD. Med Clin North Am. 2010;94(1):35-52.
Zisman TL, Rubin DT. Novel diagnostic and prognostic modalities in inflammatory bowel disease. Med Clin North Am. 2010;94(1):155-178.

Codes

ICD9

555.9 Regional enteritis of unspecified site
556.9 Ulcerative colitis, unspecified
558.9 Other and unspecified noninfectious gastroenteritis and colitis
555.2 Regional enteritis of small intestine with large intestine
555.0 Regional enteritis of small intestine
555.1 Regional enteritis of large intestine
555 Regional enteritis
556.1 Ulcerative (chronic) ileocolitis
556.2 Ulcerative (chronic) proctitis
556.3 Ulcerative (chronic) proctosigmoiditis
556.5 Left-sided ulcerative (chronic) colitis
556.6 Universal ulcerative (chronic) colitis
556.8 Other ulcerative colitis

ICD10

K50.90 Crohns disease, unspecified, without complications
K51.90 Ulcerative colitis, unspecified, without complications
K52.9 Noninfective gastroenteritis and colitis, unspecified
K50.80 Crohn's disease of both small and lg int w/o complications
K50.00 Crohn's disease of small intestine without complications
K50.10 Crohn's disease of large intestine without complications
K51.00 Ulcerative (chronic) pancolitis without complications
K51.20 Ulcerative (chronic) proctitis without complications
K51.30 Ulcerative (chronic) rectosigmoiditis without complications
K51.50 Left sided colitis without complications
K51.80 Other ulcerative colitis without complications

SNOMED

24526004 Inflammatory bowel disease (disorder)
34000006 Crohns disease (disorder)
64766004 Ulcerative colitis (disorder)
71833008 Crohn's disease of small AND large intestines
13470001 Chronic ulcerative ileocolitis (disorder)
444548001 Ulcerative pancolitis (disorder)
445243001 Left sided ulcerative colitis (disorder)
56689002 Crohn's disease of small intestine
7620006 Crohn's disease of large bowel

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