UC: bloody diarrhea, continuous from rectum. Crohn: skip lesions, transmural, fistula, granulomas
Diagnose: Colonoscopy (distinguish UC vs Crohn)
Baseline / maintenance: Mesalamine (5-ASA)
Flare: Steroids (IV methylprednisolone / oral prednisone / budesonide)
Steroid-dependent → azathioprine / biologics (infliximab, adalimumab)
Order set
- FBC, CRP, ESR
- Stool culture + C. diff + calprotectin
- Colonoscopy + biopsy
- Iron/B12/vit D
- Acute severe UC (Truelove-Witts): assess IV-steroid response at day 3 (Oxford/Travis) → infliximab or ciclosporin rescue; colectomy if failure
- LMWH VTE prophylaxis for all hospitalized IBD flares (even with rectal bleeding)
Criteria
AdmitSevere flare (Truelove-Witts) or complications
ICUToxic megacolon, perforation, shock
TransfuseHb <70 g/L
DischargeFlare settling, tolerating diet, maintenance + surgical review if needed
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Toxic megacolon
- Severe flare (Truelove-Witts)
- Perforation
Differentials
- Infective colitis
- Ischaemic colitis
- IBS
- Coeliac
Common mistakes
- Steroids without infection exclusion
- Missing toxic megacolon
Disposition & follow-up
Induce remission then maintain; severe → admit + surgery input.
Discharge package
MedicationsMaintenance (mesalamine/immunomodulator/biologic); steroid taper
Follow-upGastroenterology; drug monitoring
VaccinationPre-biologic screen; avoid live vaccines on immunosuppression
LifestyleSmoking cessation (Crohn)
Warning symptomsBloody diarrhoea, fever, severe pain, distension
💊 Treatment detail — doses & preparation
Mesalazine (5-ASA)aminosalicylate
DosePO 2.4–4.8 g/day OD–divided; rectal 1 g OD for distal disease
Preparation400/800 mg MR tablets (take whole); suppository/enema for proctitis
MonitorRenal function annually, pancreatitis paradox
Prednisolonecorticosteroid
DoseIBD flare: 40 mg OD, taper over ~6–8 wk (never stop abruptly; always taper in IBD). Acute severe UC: IV methylprednisolone 60 mg/day (or hydrocortisone 300–400 mg/day)
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Azathioprinethiopurine immunosuppressant
Dose2–2.5 mg/kg OD (IBD, myositis, MG)
Preparation25/50 mg tablets with food
MonitorFBC + LFT weekly ×4 then q8–12 wk; TPMT before starting; avoid allopurinol combination
Infliximabanti-TNF
Dose5 mg/kg IV at wk 0, 2, 6 then q8 wk
Preparation100 mg vial reconstitute, infuse over 2 h with observation
MonitorTB/hepatitis B screen first; infusion reactions; avoid live vaccines
📖 ACG / ECCO IBDReviewed July 2026