Inflammatory bowel disease flareMANAGEMENT

GASTROINTESTINAL PRESENTATIONS · 12 SECTIONS

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528 items

☷ Legend

01Approach to the Critical Patient/attcp44

Immediate threats

›Immediate threats

›Hemodynamic instability

›If hypotension, resuscitation bay

›If shock, broad differential including sepsis, hemorrhage, perforation

›Toxic megacolon concern

›If severe abdominal distension with systemic toxicity, immediate abdominal radiograph

›If colonic diameter 6 cm or greater with toxicity, urgent GI and surgery

›Peritonitis concern

›If rigidity or rebound, CT abdomen pelvis with IV contrast and surgical consult

›Massive gastrointestinal bleeding

›If ongoing large volume hematochezia with instability, massive transfusion pathway

›Severe dehydration and electrolyte derangement

›If altered mental status or arrhythmia risk, telemetry and rapid correction

Initial stabilization bundle

›Stabilization bundle

›Monitoring and access

›Continuous pulse oximetry

›Cardiac monitor for significant electrolyte abnormality

›Two large bore IV lines

›Fluid resuscitation

›Isotonic crystalloid bolus for hypovolemia

›Reassess after each bolus using blood pressure and urine output

›Early antibiotics only when indicated

›If sepsis, perforation, abscess, or cholangitis, initiate broad spectrum coverage

›If uncomplicated acute severe ulcerative colitis without infection, avoid adjunctive antibiotics

›Early specialty activation

›GI consult for hospitalized flare or acute severe ulcerative colitis

›Surgery consult for toxic megacolon, perforation, refractory hemorrhage, obstruction not improving

›Medication safety

›Avoid NSAIDs

›Avoid antimotility agents if severe colitis or megacolon concern

›If high dose steroids planned, infection workup before initiation when feasible

Severity triage targets

›Severity triage

›Acute severe ulcerative colitis screen

›Stool frequency 6 or more per day with blood

›Systemic toxicity features

›Temperature 37.8 C or higher

›Heart rate 90 or higher

›Hemoglobin low for age and sex

›CRP elevated

›Complicated Crohn disease screen

›Obstructive symptoms

›Suspected intraabdominal abscess

›Perianal sepsis

›High fever or sepsis physiology

02History/hx56

Flare characterization

›Flare characterization

›Diagnosis context

›Ulcerative colitis location history

›Crohn disease phenotype

›Inflammatory

›Stricturing

›Penetrating

›Perianal

›Symptom pattern

›Stool frequency trend

›Blood and mucus

›Nocturnal stools

›Urgency and tenesmus

›Abdominal pain location

›Nausea and vomiting

›Severity markers

›Fever or chills

›Syncope or presyncope

›Oliguria

›Weight loss

›Poor oral intake

Triggers and alternate etiologies

›Triggers and alternate etiologies

›Infectious triggers

›Recent antibiotics

›Recent hospitalization

›Sick contacts

›Travel and food exposures

›Medication factors

›Nonadherence to maintenance therapy

›Recent steroid taper

›Recent biologic infusion timing

›NSAID exposure

›Immune suppression risks

›Current biologic or JAK inhibitor use

›Thiopurine or methotrexate use

›Recent high dose steroids

›Complication clues

›Progressive distension

›Obstipation

›Severe focal pain

›Perianal pain or drainage

›Dysuria or pneumaturia

Extraintestinal manifestations and red flags

›Systemic features

›Extraintestinal manifestations

›Uveitis symptoms

›Oral ulcers

›Erythema nodosum

›Pyoderma gangrenosum

›Peripheral arthritis

›Axial back pain

›Thromboembolism symptoms

›Pleuritic chest pain

›Unilateral leg swelling

›Pregnancy and fertility context

›Pregnancy possibility

›Postpartum status

03Physical Exam/exam35

General and hemodynamics

›General and hemodynamics

›Appearance

›Toxic appearance

›Dehydration signs

›Vitals

›Fever pattern

›Tachycardia

›Hypotension or orthostasis

›Perfusion

›Capillary refill

›Mental status

Abdominal and perineal exam

›Abdominal and perineal

›Abdominal exam

›Distension

›Bowel sounds

›Diffuse tenderness

›Focal tenderness

›Guarding or rebound

›Rectal and perianal exam when appropriate

›Gross blood

›Fissure

›Abscess fluctuance

›Fistula opening or drainage

›Stoma exam when present

›Output volume

›Peristomal skin integrity

Extraintestinal exam

›Extraintestinal

›Skin

›Erythema nodosum lesions

›Ulcerative lesions consistent with pyoderma

›Eyes

›Conjunctival injection and photophobia

›Joints

›Peripheral synovitis

›Sacroiliac tenderness

04Differential Diagnosis/ddx33

Bloody diarrhea and colitis phenotype

›Bloody diarrhea and colitis

›Ulcerative colitis flare

›ICD-10 K51 dot 9

›SNOMED CT ulcerative colitis

›Crohn colitis flare

›ICD-10 K50 dot 1

›SNOMED CT Crohn disease

›Infectious colitis

›Clostridioides difficile infection

›Campylobacter

›Salmonella

›Shigella

›Shiga toxin producing E coli

›CMV colitis in immunosuppressed

›Ischemic colitis

›Older age or vascular risk

›Medication related colitis

›NSAID associated colitis

›Immune checkpoint inhibitor colitis

Abdominal pain and complication phenotype

›Abdominal pain and complications

›Toxic megacolon

›Colonic dilation with systemic toxicity

›Perforation

›Peritonitis signs

›Intraabdominal abscess

›Fever with focal tenderness

›Small bowel obstruction

›Vomiting and obstipation

›Appendicitis

›Right lower quadrant focality

›Ovarian and gynecologic causes

›Ectopic pregnancy

›Ovarian torsion

05Laboratory Tests/lt40

Core labs for severity and safety

›Core labs

›Hematology

›Complete blood count for anemia and leukocytosis

›Neutrophilia compatible with inflammation or steroids

›Severe anemia as marker of hemorrhage or chronic disease

›Chemistry

›Electrolytes for dehydration and diarrhea losses

›Potassium depletion risk

›Magnesium depletion risk

›Creatinine for volume status and medication dosing

›Albumin for severity and drug pharmacokinetics

›Inflammation

›CRP for severity trend

›ESR optional for trend context

›Hepatobiliary

›ALT AST ALP GGT bilirubin for PSC or drug injury

›Coagulation

›INR for liver dysfunction and procedural planning

›Lactate when shock, sepsis, or ischemia concern

›Venous blood gas with lactate in unstable patients

Stool and infection evaluation

›Stool evaluation

›C difficile testing

›NAAT or two step algorithm per local lab

›High priority before escalating immunosuppression

›Bacterial stool testing

›Culture or multiplex PCR panel based on availability

›Shiga toxin testing when clinically indicated

›Ova and parasites when risk factors present

›Travel exposure

›Prolonged symptoms

›Fecal calprotectin when outpatient differentiation needed

›Higher values support inflammatory activity

Immunosuppression safety labs

›Immunosuppression safety

›Pregnancy test before teratogenic or radiologic exposure

›Blood cultures if febrile or septic

›Viral hepatitis screening when starting biologics if not previously done

›Hepatitis B surface antigen and core antibody

›TB screening when starting biologics if not previously done

›IGRA preferred in BCG vaccinated

›If severe flare with planned rescue therapy, baseline lipid and magnesium for calcineurin inhibitor safety

06Diagnostic Tests/dt64

Scoring Systems

›Scoring systems

›Truelove and Witts acute severe ulcerative colitis criteria

›Stool frequency 6 or more per day with blood

›At least one systemic toxicity feature

›Temperature 37.8 C or higher

›Heart rate 90 or higher

›Hemoglobin low for age and sex

›CRP elevated

›Mayo score for ulcerative colitis activity

›Stool frequency subscore

›Rectal bleeding subscore

›Endoscopic appearance subscore

›Physician global assessment subscore

›Harvey Bradshaw Index for Crohn disease activity

›General well being

›Abdominal pain

›Liquid stools per day

›Abdominal mass

›Complications count

›Pediatric Ulcerative Colitis Activity Index

›Stool frequency

›Rectal bleeding

›Abdominal pain

›Activity level

›Nocturnal stools

›Examination findings

MRI

›MRI

›MR enterography for Crohn small bowel assessment

›Active inflammation features

›Wall thickening and hyperenhancement

›Edema

›Complication features

›Fistula tracts

›Abscess

›Stricture characterization

›Pelvic MRI for perianal Crohn disease

›Fistula classification

›Abscess mapping for drainage planning

›Safety and logistics

›Gadolinium avoidance in severe renal impairment when possible

›Longer acquisition time compared with CT

›CT

›CT abdomen pelvis with IV contrast for complication evaluation

›Abscess detection

›Pericolonic or intraabdominal collections

›Obstruction evaluation

›Transition point

›Closed loop concern

›Perforation evaluation

›Free air

›Free fluid

›CT enterography in selected Crohn evaluations

›Small bowel inflammation and strictures

›Acute severe colitis imaging adjunct

›If toxic megacolon concern, abdominal radiograph preferred for serial diameter tracking

Ultrasound

›Ultrasound

›Point of care ultrasound adjuncts

›IVC assessment for volume status adjunct

›Free fluid assessment when perforation concern

›Perianal and superficial abscess evaluation

›Bedside soft tissue ultrasound for fluctuance confirmation

›Hepatobiliary ultrasound when cholestasis pattern

›Gallstones

›Bile duct dilation

07Disposition/dispo27

Admission and level of care

›Admission and level of care

›Admit indications

›Acute severe ulcerative colitis criteria met

›Inability to maintain hydration or oral intake

›Severe pain requiring parenteral analgesia

›Significant anemia requiring transfusion

›Electrolyte derangement requiring IV replacement

›Suspected abscess, obstruction, perforation, or toxic megacolon

›Systemic infection concern in immunosuppressed

›ICU indications

›Shock physiology

›Ongoing major hemorrhage

›Toxic megacolon with systemic instability

›Postoperative or high risk airway needs

Discharge criteria for mild flare

›Discharge criteria

›Clinical stability

›Normal blood pressure without IV fluids

›No high fever

›Tolerating oral hydration

›Low complication concern

›No peritonitis

›No severe distension

›No persistent vomiting

›Outpatient plan secured

›Rapid GI follow up arranged

›Stool studies plan if not completed

›Clear return precautions provided

08Treatment/t118

Supportive care

›Supportive care

›Fluids and electrolytes

›Isotonic crystalloid

›Titrate boluses to perfusion and urine output

›Reassess after each bolus

›Potassium replacement

›If potassium low, replete per local protocol

›Telemetry if severe hypokalemia

›Magnesium replacement

›If magnesium low, replete per local protocol

›Co replete with potassium when both low

›Analgesia and antiemetics

›Acetaminophen

›Maximum daily dose per hepatic status

›Avoid combination duplicates

›Opioids with caution in severe colitis

›If needed, lowest effective dose

›Monitor for ileus and megacolon

›Antiemetic options

›Ondansetron

›QT risk review in electrolyte derangement

›Nutrition

›Enteral nutrition preferred when tolerated

›Avoid routine bowel rest

›Total parenteral nutrition not used solely for bowel rest in acute severe ulcerative colitis

›Venous thromboembolism prophylaxis

›Pharmacologic prophylaxis for hospitalized flares unless contraindicated

›Low molecular weight heparin dosing per weight and renal function

›Continue despite non massive hematochezia when safe

Ulcerative colitis flare pharmacotherapy

›Ulcerative colitis pharmacotherapy

›Mild to moderate outpatient flare

›Oral mesalamine

›Total daily dose 2 g to 4.8 g

›Once daily or divided based on formulation

›Rectal mesalamine for distal disease

›Suppository 1 g nightly or enema per formulation

›Add to oral therapy for proctitis or left sided disease

›Oral corticosteroid for inadequate response

›Prednisone 40 mg daily

›Taper after response with steroid sparing plan

›Acute severe ulcerative colitis inpatient induction

›IV corticosteroids

›Methylprednisolone IV 40 mg to 60 mg daily

›Reassess response at day 3

›Hydrocortisone IV 100 mg every 6 hours alternative

›Avoid doses higher than guideline range without clear rationale

›DVT prophylaxis concurrent

›Initiate unless contraindicated

›High VTE risk in active colitis

›Avoid adjunctive antibiotics without infection

›Do not add empiric antibiotics solely for acute severe ulcerative colitis

›Steroid refractory acute severe ulcerative colitis rescue

›Rescue decision at day 3 to day 5 of IV steroids

›If inadequate response by day 3, initiate rescue pathway

›Early surgical discussion in parallel

›Infliximab

›5 mg per kg IV induction dose

›Repeat at week 2 and week 6 standard schedule

›Consider accelerated dosing protocol per local expert pathway

›Cyclosporine

›Continuous IV infusion 2 mg per kg per day

›Target trough level 150 ng per mL to 250 ng per mL per local protocol

›Transition to oral cyclosporine with bridging plan when stabilized

›Sequential rescue caution

›Avoid routine infliximab after cyclosporine or cyclosporine after infliximab due to adverse event risk

›If considering third line rescue, multidisciplinary decision with surgery

Crohn disease flare pharmacotherapy

›Crohn pharmacotherapy

›Mild ileocecal disease

›Budesonide controlled ileal release 9 mg daily

›Typical course up to 8 weeks then taper

›Not for severe disease or extensive colitis

›Moderate to severe luminal flare

›Systemic corticosteroid induction

›Prednisone 40 mg to 60 mg daily

›Taper with steroid sparing maintenance plan

›If inpatient severe flare, methylprednisolone IV 40 mg to 60 mg daily

›Reassess within 72 hours

›Biologic or small molecule escalation with GI

›Anti TNF therapy options

›Infliximab or adalimumab

›Consider combination with thiopurine in selected patients per risk profile

›Vedolizumab option

›Gut selective mechanism for induction and maintenance

›Ustekinumab option

›IL 12 23 pathway

›Perianal or fistulizing disease adjuncts

›Antibiotics as adjunct when infection or perianal sepsis concern

›Metronidazole option

›Neuropathy risk with prolonged use

›Ciprofloxacin option

›Tendinopathy and QT risk review

›Drainage for abscess

›If abscess present, source control before escalation of immunosuppression

Complication specific management

›Complication management

›Toxic megacolon pathway

›Bowel rest

›NPO with close monitoring

›Avoid opioids when possible

›Broad spectrum antibiotics

›If megacolon suspected, cover gram negative and anaerobes

›Add coverage per local sepsis protocol

›High dose IV steroids for inflammatory etiology

›If suspected IBD driven megacolon, IV corticosteroids per acute severe ulcerative colitis protocol

›Immediate surgical involvement

›Obstruction in Crohn disease

›Cross sectional imaging confirmation

›Differentiate inflammatory edema versus fixed fibrotic stricture

›Surgical and GI co management

›Nasogastric decompression when persistent vomiting

›Titrate based on output and symptoms

›Intraabdominal abscess

›Antibiotics plus drainage strategy

›Percutaneous drainage when accessible

›Culture directed narrowing when results available

›Severe anemia

›Transfusion thresholds individualized

›If symptomatic anemia or hemodynamic compromise, transfuse

›Iron repletion planning after stabilization

09Special Populations/sp41

Pregnancy

›Pregnancy

›Maternal fetal priorities

›Disease control prioritized to reduce adverse outcomes

›Active disease higher risk than most maintenance medications

›Medication safety highlights

›Avoid methotrexate

›Teratogenic and contraindicated

›Corticosteroids acceptable for induction when needed

›Monitor gestational diabetes and hypertension risk

›Anti TNF therapy generally compatible through pregnancy

›Timing of late gestation dosing individualized

›Imaging preferences

›Ultrasound and MRI preferred when feasible

›CT only when urgent diagnostic need

Geriatric

›Geriatric

›Presentation and risk

›Higher infection risk on immunosuppression

›Lower fever response possible

›Medication considerations

›Steroid adverse effects amplified

›Delirium risk

›Hyperglycemia risk

›Thromboembolism prophylaxis emphasis

›Balance bleeding risk with high baseline VTE risk

›Alternate diagnoses

›Ischemic colitis higher likelihood

›Vascular history and hypotension context

Pediatrics

›Pediatrics

›Severity scoring

›PUCAI for ulcerative colitis activity

›Hospitalization thresholds per pediatric GI pathway

›Steroid dosing patterns

›Prednisone 1 mg per kg per day typical induction

›Maximum dose per pediatric protocol

›IV methylprednisolone 1 mg per kg per day to 1.5 mg per kg per day inpatient

›Maximum 60 mg per day common cap

›Growth and nutrition focus

›Malnutrition screening

›Early dietitian involvement

›Exclusive enteral nutrition option in Crohn disease induction

›Pediatric centered strategy with specialist guidance

10Background/b32

Epidemiology

›Epidemiology

›Disease burden

›Chronic relapsing inflammatory disorders of gastrointestinal tract

›Ulcerative colitis limited to colon

›Crohn disease can involve any GI segment

›Peak onset pattern

›Young adult predominance with secondary older age peak

›Family history increases risk

Pathophysiology

›Pathophysiology

›Immune dysregulation

›Mucosal immune activation with barrier dysfunction

›Microbiome and environmental interactions

›Ulcerative colitis features

›Continuous mucosal inflammation starting at rectum

›Superficial ulceration with bleeding

›Crohn disease features

›Transmural inflammation with skip lesions

›Strictures from fibrosis

›Fistulas from penetrating disease

Therapeutic Considerations

›Therapeutic considerations

›Steroids as induction only

›Not effective for maintenance in Crohn disease

›Steroid sparing transition required

›Biologic therapy goals

›Symptom control plus mucosal healing

›Reduced hospitalization and surgery risk

›Infection risk management

›Screen and vaccinate when possible before immunosuppression

›Monitor for opportunistic infections during flares

›Antibiotics role

›Not routine for uncomplicated ulcerative colitis flare

›Targeted use for abscess or sepsis

11Patient Discharge Instructions/pdi22

copy discharge instructions

›copy discharge instructions

›Diagnosis and plan

›Flare of inflammatory bowel disease possible

›Medication plan as prescribed

›Hydration and diet

›Oral fluids with electrolytes

›Small frequent meals as tolerated

›Medication cautions

›Avoid NSAIDs

›Avoid loperamide if severe abdominal pain, distension, or fever

›Follow up

›GI follow up within 1 week or sooner if worsening

›Stool test follow up if sent

›Return to ER now for red flags

›Fainting or severe weakness

›Inability to keep fluids down

›Fever 38.0 C or higher with worsening symptoms

›Severe or increasing abdominal pain

›New abdominal distension or no gas or stool

›Large volume blood in stool or black tarry stool

›Chest pain or shortness of breath

›New one sided leg swelling

12References/r16

Clinical guidelines and key sources

›Clinical guidelines and key sources

›ACG Clinical Guideline Ulcerative Colitis in Adults 2019

›Acute severe ulcerative colitis IV steroids methylprednisolone 60 mg per day or hydrocortisone 100 mg three to four times daily

›AGA Clinical Guidance Management of Moderate to Severe Ulcerative Colitis

›IV methylprednisolone dose equivalent 40 mg to 60 mg daily in hospitalized acute severe ulcerative colitis

›British Society of Gastroenterology guideline on inflammatory bowel disease 2025

›Rescue therapy timelines and colectomy triggers in acute severe ulcerative colitis

›ACG Clinical Guideline Crohn Disease 2025 update

›Corticosteroids induction only and early steroid sparing strategy

›Canadian Association of Gastroenterology Clinical Practice Guideline Luminal Crohn Disease 2019

›Anti TNF and newer biologic sequencing recommendations

›ECCO Guidelines on Therapeutics in Ulcerative Colitis Surgical Treatment 2022

›Surgical indications and perioperative considerations

›Evidence labeling note

›ACEP Level A B C not established for inflammatory bowel disease flare specific pathways

›Class I IIa IIb terminology used only when explicitly stated in cited society guidance

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.