Inpatient Management of Inflammatory Bowel Disease Flares with Bloody Stools
1.0 Purpose and Scope
This protocol provides a standardized, evidence-based framework for the systematic management of hospitalized patients presenting with inflammatory bowel disease (IBD) flares accompanied by bloody stools. Its strategic importance lies in ensuring timely, appropriate interventions and systematic risk stratification to improve patient outcomes while minimizing complications associated with both the disease and its treatments. This document outlines the critical first steps of patient evaluation upon hospital arrival, guiding clinicians through a structured pathway from initial stabilization to definitive therapy.
2.0 Immediate Assessment and Stabilization
The initial moments after a patient presents are critical for establishing a safe clinical course. Immediate stabilization and rapid initial diagnostics are paramount, as these actions form the foundation for all subsequent risk stratification and therapeutic decisions. The primary goals are to assess hemodynamic stability, correct fluid and electrolyte imbalances, and gather essential laboratory and stool studies before initiating disease-specific therapy.
Initial Orders and Interventions
Critical Directive: Hold all IBD-specific therapies, especially corticosteroids, until infection has been reasonably excluded, except in cases of fulminant colitis with an immediate life-threatening presentation.
These initial steps are designed to stabilize the patient while simultaneously initiating the workup to differentiate an infectious process from a true IBD flare.
3.0 Differentiating Infection from IBD Flare
Ruling out a superimposed infection is the single most critical decision point before initiating or escalating immunosuppressive therapy. Misdiagnosing an infection as a pure IBD flare and administering corticosteroids or biologics can lead to a fulminant course, increased morbidity, and worsened patient outcomes. Clinicians must be aware that highly sensitive multiplex PCR stool panels may detect pathogenic DNA that represents colonization rather than active infection. Therefore, a positive result must be interpreted in the full clinical context.
Prioritizing Infection Management
If a treatable pathogen—such as C. difficile, Cytomegalovirus (CMV), Salmonella, Shigella, or Campylobacter—is identified, the infection must be the primary target of therapy. Escalation of IBD-specific treatment should only be considered if symptoms of active colitis persist after 48-72 hours of appropriate antimicrobial or antiviral therapy.
Once infection is deemed unlikely or is being appropriately treated, the next step is to formally stratify the severity of the IBD flare.
4.0 Severity Stratification
Accurate severity stratification is essential for guiding the intensity and timing of medical therapy. This assessment allows clinicians to match the treatment approach to the patient's risk profile, ensuring that severe disease receives aggressive inpatient management while milder cases are not over-treated. This distinction is critical: UC severity is driven by mucosal inflammation and its systemic effects (stool frequency, bleeding, toxicity), whereas CD severity is primarily defined by its transmural nature and propensity for structural complications (obstruction, abscess, perforation).
4.1 Ulcerative Colitis (UC) Severity
Severity in UC is primarily determined by stool frequency, the presence of blood, and signs of systemic toxicity, as defined by the Truelove & Witts criteria.
Severe UC: Defined as having ≥6 bloody stools per day PLUS at least one sign of systemic toxicity:
Practical Laboratory Cutoff: In modern practice, a CRP >30 mg/L is also consistent with a severe flare.
Fulminant UC: >10 stools per day, continuous bleeding, abdominal tenderness/distention, transfusion requirement.
Moderate UC: 4-6 stools per day, intermediate between mild and severe.
Mild UC: <4 stools per day, small amounts of blood, no systemic toxicity.
4.2 Crohn's Disease (CD) Severity
In contrast to UC, the severity of a Crohn's disease flare is primarily driven by the presence of systemic illness and structural complications, not stool frequency.
Severe/Fulminant CD: Defined by the presence of one or more of the following:
Practical Laboratory Cutoff: A CRP >45 mg/L is associated with severe disease activity and a higher risk of steroid failure.
This severity assessment directly informs the initial set of inpatient management orders.
5.0 Core Inpatient Management Orders
Beyond disease-specific medical therapy, a standardized set of core supportive care orders is crucial for all hospitalized IBD patients. These orders are designed to manage symptoms, prevent complications, and improve patient tolerance to treatment.
These core orders are complemented by diagnostic procedures to confirm disease severity and guide the therapeutic strategy.
6.0 Endoscopic and Imaging Strategy
The strategic use of endoscopy and imaging is essential to confirm the severity of a flare, rule out complications, and obtain tissue for histology. The approach must balance the diagnostic yield of a procedure against the potential risks in an acutely inflamed bowel.
6.1 Ulcera...
