Management of inflammatory bowel disease in the emergency setting: WSES-AAST guidelines

Written By : Dr Satabdi Saha |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2021-05-21T10:55:35+05:30 | Updated On 21 May 2021 3:27 PM IST

Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. With this in mind, The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons.

To formulate this guideline, a group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019.

Recommendation 1

We recommend assessing Crohn's disease or Ulcerative colitis disease activity in the urgent clinical situation by performing the following laboratory tests: a full blood count, including haemoglobin, leukocytes count and platelet count; serum C-reactive protein level, erythrocyte sedimentation rate level, serum electrolytes, liver enzymes level, serum albumin, renal function and faecal calprotectin level, when it is possible. It's mandatory to exclude any infectious diseases by performing blood-, stool cultures and toxin test for Clostridium difficile (Strong recommendation based on a moderate level of evidence 1B).

Recommendations 2

We recommend investigating the acute abdomen in IBD patients with IV contrast-enhanced computed tomography scan in the emergency setting, to exclude the presence of intestinal perforation, stenosis, bleeding and abscesses and to help guide decision making for immediate surgery or initial conservative management (Strong recommendation based on low level evidence 1C).

We suggest performing a point of care ultrasonography (if skills are available) when computed tomography scan is not available, in order to assess the presence of free intra-abdominal fluid, intestinal distension or abscess. The magnetic resonance enterography, (if available) is the preferred technique to diagnose strictures, to differentiate fibrotic from inflammatory components and disease activity (Weak recommendation based on low level evidence 2C).

In stable patients presenting with signs of gastrointestinal bleeding, we recommend performing a computed tomography angiography to localise the bleeding site before angio-embolisation or surgery (Weak recommendation based on low level evidence 2C).

If computed tomography and ultrasonography are unavailable, we suggest referring stable patients to a hospital where 24/7 emergency imaging is available (Weak recommendation based on very low level evidence 2D)

Recommendations 3

We recommend performing radiological percutaneous drainage of intra-abdominal abscesses > 3 cm related to Crohn's disease associated with early empiric administration of antibiotics, to adapt these as soon as possible to microbiological cultures results. The antimicrobial therapy should be re-evaluated according to patient's clinical and biochemical features (Strong recommendation based on a low level evidence 1C).

We recommend administering an early empiric antimicrobial therapy in stable patients presenting with abscess < 3 cm, with close clinical and biochemical monitoring (Strong recommendation based on a low level evidence 1C).

Recommendations 4

We recommend evaluating medical treatment in IBD patients presenting with acute abdominal pain and disease activity in a multidisciplinary approach (Strong recommendation based on low level evidence 1C).

We recommend not routinely administrating antibiotics in IBD patients but only in the presence of superinfection, intra-abdominal abscesses, and sepsis (Strong recommendation based on high level evidence1A)

We recommend administering antibiotics according to the epidemiology and resistance of the setting in a duration that depends on the patient's clinical and biolchemical findings. Antifungals should be reserved for high risk patients such as those with bowel perforation and recent steroid treatment. (Strong recommendation based on high level evidence 1A)

We recommend administering as soon as possible venous thromboembolism prophylaxis with LMWH for the high risk of thrombotic events related to complicated IBD and the emergency setting (Strong recommendation based on high level evidence 1A)

We recommend weaning off steroids (wean preoperatively, ideally 4 weeks) and stopping immunomodulators associated with anti-TNF-α agents before surgery, as soon as possible to decrease the risk of postoperative complications, in accordance with a gastroenterologist (Strong recommendation based on moderate level evidence 1B)

We recommend administering nutritional support (parenteral or enteral, according to GI function and in conjunction with a dietician/nutrition team) in IBD patients as soon as possible (Strong recommendation based on moderate level evidence 1B)

Recommendations 5.1

We suggest evaluating all hemodynamically stable patients presenting with acute severe ulcerative colitis in a multidisciplinary approach with the gastroenterologist to decide on options for initial medical treatment (Weak recommendation based on low level evidence 2C).

Recommendations 5.3

We recommend performing immediate surgery in unstable patients presenting with hemorrhagic shock, and non responders to resuscitation. An intra-operative ileoscopy, if available, could be useful in localising the bleeding source in patients with Crohn's disease. In patients presenting with acute severe ulcerative colitis and refractory haemorrhage, non responders to medical treatment, the surgical treatment of choice is a subtotal colectomy with ileostomy, if skills are present (Strong recommendation based on low level evidence 1C).

We suggest evaluating hemodynamically stable IBD patients presenting with a gastrointestinal bleeding at first with a sigmoidoscopy and an esophagogastroduodenoscopy (Weak recommendation based on low level evidence 2C)

Recommendation 5.4

We recommend performing surgical exploration in the presence of radiological signs of pneumoperitoneum and free fluid within the peritoneal cavity in acutely unwell patients presenting with complicated Crohn's disease or acute severe ulcerative colitis (Strong recommendation based on low level evidence 1C).

We recommend performing emergency surgical exploration in hemodynamically unstable patients, according to damage control principles and in patients presenting with colonic perforation. Subtotal colectomy with ileostomy is the surgical treatment of choice in patients acute severe ulcerative colitis patients presenting massive colorectal haemorrhage or non responders to medical treatment (Strong recommendation based on high level evidence 1A)

Recommendationss 6

We recommend performing a surgical exploration by laparotomy in a hemodynamically unstable patient presenting with complications related to IBD such as perforation and severe peritonitis, massive intestinal bleeding, obstruction, toxic megacolon, severe colitis non responder to medical treatment, taking in to consideration damage control surgery principles with or without an open abdomen (Strong recommendation based on low level evidence 1C).

We recommend performing a laparoscopic approach in hemodynamically stable patients presenting with complications related to IBD, when skills are available, in order to decrease morbidity and length of hospital stay (Strong recommendation based on low level evidence 1C).

We recommend performing a subtotal colectomy with ileostomy in patients presenting with acute severe refractory colitis, and massive colorectal bleeding non responders to medical treatment, in a laparoscopic or open approach according to patient's hemodynamic stability and surgeon's skill (Strong recommendation based on low level evidence 1C).

We suggest considering an (stapled or hand sewn) anastomosis in hemodynamically stable patients with Crohn's disease who have good pre-existing nutritional status and who are taking no steroids or other immunosuppression and presenting with no bowel vascular compromise and only localised peritonitis. A defunctioning stoma should also be considered in the emergency setting. (Weak recommendation based on low level evidence 2C)

Recommendation 7

We recommend performing adequate surgical drainage of perianal abscess in Crohn's disease without searching for an associated fistula (Strong recommendation based on low level evidence 1C)

"Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate."the team concluded.

Forr full article follow the link: https://doi.org/10.1186/s13017-021-00362-3

Primary source: World Journal of Emergency Surgery

Inflammatory bowel diseaseCrohn diseaseEmergency surgeryGuidelinesWorld Journal of Emergency Surgery

Source : World Journal of Emergency Surgery

Dr Satabdi Saha

Dr Satabdi Saha (BDS, MDS) is a practicing pediatric dentist with a keen interest in new medical researches and updates. She has completed her BDS from North Bengal Dental College ,Darjeeling. Then she went on to secure an ALL INDIA NEET PG rank and completed her MDS from the first dental college in the country – Dr R. Ahmed Dental College and Hospital. She is currently attached to The Marwari Relief Society Hospital as a consultant along with private practice of 2 years. She has published scientific papers in national and international journals. Her strong passion of sharing knowledge with the medical fraternity has motivated her to be a part of Medical Dialogues.

Dr. Kamal Kant Kohli

Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751