Rosen & Barkin's 5-Minute Emergency Medicine Consult (394 page)

• Perianal:
  
  • Crohn's 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
      

• May present as initial onset of disease or exacerbation of existing disease.
  
• Maintain high index of suspicion because of subtle presentation of Crohn's disease.
  

• 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.
  

• 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 Crohn's.
    
• 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.
  

• 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

Vital sign stabilization as per BLS

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

• 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 Crohn's with colon/perineal involvement.
      
    • Immunosuppressive agents (azathioprine, methotrexate) are used in severe disease.
      
    • Monoclonal antibodies neutralize cytokine tumor necrosis factor (TNF)-α and inhibit binding to TNF-α 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.

• 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

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

• 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
  

Extraintestinal manifestations

• Ocular
  
• Dermatologic
  

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

• With severe flare, rule out toxic megacolon.
  
• Consider Crohn's 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.
  

• 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.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Abdominal Pain
  
• Diarrhea
  

CODES

• 555.9 Regional enteritis of unspecified site
  
• 556.9 Ulcerative colitis, unspecified
  
• 558.9 Other and unspecified noninfectious gastroenteritis and colitis