『Inpatient IBD Flare』のカバーアート

Inpatient IBD Flare

Inpatient IBD Flare

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 Inpatient Management of Inflammatory Bowel Disease Flares with Bloody Stools1.0 Purpose and ScopeThis 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 StabilizationThe 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 InterventionsVital Signs: Assess and document BP, HR, temp, RR, and orthostatics to gauge hemodynamic stability.Intravenous Access: Establish 2 large-bore IVs for fluid resuscitation and potential transfusion.Fluid Resuscitation: Initiate IV fluids to correct dehydration and maintain hemodynamic stability.Initial Laboratory Panels: Order a complete blood count (CBC), comprehensive metabolic panel (CMP), C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR), a coagulation profile, and a Type & Cross.Essential Stool Studies: Order stool studies to rule out infectious etiologies, including Clostridioides difficile toxin/PCR, stool culture for enteric pathogens, and ova and parasites if epidemiologically indicated.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 FlareRuling 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 ManagementIf 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 StratificationAccurate 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) SeveritySeverity 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:Fever >37.8°C (100.0°F)Heart Rate >90 beats per minuteHemoglobin <10.5 g/dLErythrocyte Sedimentation Rate (ESR) ≥30 mm/hrPractical 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) SeverityIn contrast to UC, the severity of a Crohn's disease flare is primarily driven by the presence of ...
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