Inflammatory Bowel DiseaseUrgent

Known ulcerative colitis; 9 bloody stools a day, cramps, fever 38.1 °C, HR 104; Hb 98 g/L, CRP 68 — acute severe UC (Truelove & Witts)

• Colonic dilatation >5.5 cm
• Peritonism, rising HR, fever on steroids
• Massive bleeding
• Hypokalaemia/hypomagnesaemia (megacolon risk)

• Infective colitis (Shigella, Salmonella, Campylobacter, C. difficile, CMV)
• Amoebic colitis
• Intestinal TB
• Ischaemic colitis (elderly)
• NSAID colitis

• Admit: Acute severe UC (Truelove & Witts) or Crohn flare with obstruction, abscess or sepsis
• ICU: Toxic megacolon, perforation, shock
• Transfuse: Hb <70–80 g/L

• Acute severe UC carries ~1% mortality today because of early rescue therapy and timely colectomy — the day-3 assessment is the pivot.
• In India, intestinal TB and amoebic colitis can mimic IBD — treating them with steroids or anti-TNF is dangerous.
• Maintenance: 5-ASA for mild UC; thiopurines or biologics after a severe flare; steroids are never maintenance.

• Start steroids without stool tests and sigmoidoscopy in a first presentation
• Give opioids, loperamide or anticholinergics in acute severe colitis (toxic megacolon)
• Withhold VTE prophylaxis because of rectal bleeding
• Start anti-TNF before screening for TB and hepatitis B

• Steroids without infection exclusion
• Missing day-3 rescue window
• Antidiarrhoeals and opioids
• No VTE prophylaxis

Ward with daily joint gastroenterology–surgery review; ICU/surgery for megacolon or perforation. IBD clinic within 2–4 weeks.