Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract, commonly seen in both acute admissions and outpatient clinics in the NHS.

Patients may present with mild symptoms or severe, life-threatening flares requiring urgent escalation.

This guide focuses on how doctors should recognise flares, assess severity, and manage patients safely on the ward and on-call.

What is IBD?

IBD includes two main conditions:

Ulcerative Colitis (UC)

Continuous inflammation
Affects colon only
Starts at rectum and spreads proximally

Crohn’s Disease

Patchy inflammation (“skip lesions”)
Anywhere from mouth → anus
Transmural (deeper inflammation)
Causes strictures and fistulas

Simple way to remember:

UC = colon only, continuous
Crohn’s = anywhere, patchy

How does it present?

Common symptoms:

Chronic diarrhoea
Blood or mucus in stool
Abdominal pain
Weight loss
Fatigue
Urgency/tenesmus

Severe flare symptoms:

Frequent bloody stools
Fever
Tachycardia
Anaemia
Dehydration
Severe abdominal pain

These patients may be systemically unwell, not just “tummy upset”.

On the ward, always ask

Is this an IBD flare or infection?

Because:

Steroids help flares
Steroids worsen infection

Always exclude infection first.

First priority = assess severity

Before thinking about medications:

Check:

NEWS score
Frequency of stools
Blood in stool
Hb
CRP
U&E
Hydration
Abdominal exam

Red flags:

Tachycardia
Hypotension
Fever
Severe pain
Guarding
Rising CRP
Hb dropping

These suggest severe colitis.

Immediate management on the ward (what juniors should actually do)

If reviewing suspected IBD flare:

Do early:

A–E assessment
Bloods: FBC, U&E, CRP, LFTs
Stool cultures
Stool C. diff
Strict fluid balance
IV access

Practical steps:

IV fluids
Correct electrolytes
Analgesia
VTE prophylaxis (very important – high clot risk)
Keep NBM if severe

Never start steroids before excluding infection.

When to suspect severe ulcerative colitis

Think acute severe colitis if:

≥6 bloody stools/day
PLUS
Fever
Tachycardia
Anaemia
Raised CRP

This is a medical emergency.

These patients often need:

IV steroids
Daily senior review
Surgical input
Close monitoring

Do not manage alone overnight.

Typical investigations

Bloods:

Anaemia common
Raised CRP
Low albumin

Stool:

Infection screen essential

Imaging:

AXR if severe (look for toxic megacolon)
CT if concern about complications

Endoscopy:

Flexible sigmoidoscopy often done acutely

Avoid full colonoscopy in severe colitis (perforation risk).

Complications you must actively think about

Acute:

Severe colitis
Toxic megacolon
Perforation
Massive bleeding
Sepsis
AKI

Chronic:

Strictures (Crohn’s)
Fistulas (Crohn’s)
Malnutrition
Colon cancer risk

Missing complications is more dangerous than missing the diagnosis.

Basic treatment overview (for junior awareness)

You won’t usually prescribe biologics yourself, but you should know the framework:

Mild–moderate:

Mesalazine

Moderate–severe:

Steroids

Maintenance:

Azathioprine / biologics

Severe:

IV steroids → biologics → surgery

Your role = recognise severity and escalate early.

When to escalate urgently

Escalate if:

Severe pain
Tachycardia
Hypotension
Fever
Hb falling
CRP rising
Abdominal distension
NEWS ≥5
Concerned nursing staff

These patients may need:

Gastro registrar review
Surgical review
HDU/ICU

Never sit on a deteriorating colitis patient.

Common mistakes juniors make

Starting steroids before excluding infection
Forgetting C. diff test
Missing VTE prophylaxis
Underestimating stool frequency
Not escalating severe cases early
Ignoring toxic megacolon risk

IBD patients can deteriorate rapidly.

Take-home concept

IBD is not just diarrhoea.
Your job is to assess severity, exclude infection, treat early, and escalate promptly when concerned.