Management of inflammatory bowel disease in the emergency setting: WSES-AAST guidelines
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.
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).
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).
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)
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).
Primary source: World Journal of Emergency Surgery