What is the initial inpatient treatment approach for a patient with a confirmed diagnosis of Inflammatory Bowel Disease (IBD), either Crohn's disease or ulcerative colitis, who has failed outpatient management or presents with severe symptoms?

Initial Inpatient Treatment of IBD

For patients hospitalized with acute severe ulcerative colitis, initiate intravenous corticosteroids immediately as first-line therapy, while patients with severe Crohn's disease complications require multidisciplinary assessment to determine whether medical therapy, percutaneous drainage, or surgery is most appropriate. 1

Immediate Assessment and Stabilization

All IBD patients presenting with acute abdomen require:

• Adequate intravenous fluid resuscitation 1
• Low-molecular-weight heparin for thromboprophylaxis 1
• Correction of electrolyte abnormalities and anemia 1
• Exclusion of Clostridioides difficile infection before escalating immunosuppression 1

Hemodynamically unstable patients require immediate surgical consultation, particularly those with perforation, life-threatening hemorrhage, or generalized peritonitis. 1

Acute Severe Ulcerative Colitis

First-Line Therapy

Intravenous corticosteroids are the initial medical treatment for hemodynamically stable patients with severe active UC. 1 This remains the standard approach for inducing remission in hospitalized patients. 2

Response Assessment

Assess response to IV steroids by day 3 of therapy. 1 This early timepoint is critical for determining whether rescue therapy or surgery is needed. 1

Second-Line (Rescue) Therapy

For non-responders who remain hemodynamically stable after 48-72 hours:

• Consider medical rescue therapy with infliximab in combination with a thiopurine, or ciclosporin 1
• This decision must be made in multidisciplinary discussion with gastroenterology and emergency surgery 1

Surgical Indications

Emergency surgery is mandatory for:

• Free perforation 1
• Life-threatening hemorrhage in unstable patients 1
• Generalized peritonitis 1
• Clinical deterioration or shock despite medical therapy 1

Subtotal colectomy with ileostomy is the surgical treatment of choice for acute severe UC requiring emergency surgery. 1

Crohn's Disease with Complications

Intra-Abdominal Abscesses

For abscesses >3 cm:

• Perform radiological percutaneous drainage 1
• Initiate early empiric antibiotics covering Gram-negative aerobic/facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli 1
• Adapt antibiotics based on culture results 1

For abscesses <3 cm:

• Administer early empiric antimicrobial therapy with close clinical and biochemical monitoring 1
• Surgery should be considered if clinical evidence of sepsis persists despite initial treatment 1

Penetrating/Fistulizing Disease

Infliximab should be considered for penetrating ileocecal Crohn's disease following adequate resolution of intra-abdominal abscesses. 1 This requires multidisciplinary discussion before initiation. 1

Antibiotic Use: Critical Caveat

Do NOT routinely administer antibiotics in IBD patients. 1 Antibiotics are indicated only for:

• Confirmed superinfection 1
• Intra-abdominal abscesses 1
• Clinical sepsis 1

This is a common pitfall—antibiotics are overprescribed in IBD flares when inflammation alone is present. 1

Nutritional Support

Preoperative nutritional support is mandatory in severely undernourished patients. 1

Total parenteral nutrition (TPN) should be reserved for:

• Nutritionally deficient patients unable to tolerate enteral nutrition 1
• Critically ill patients with shock, intestinal ischemia, high-output fistula, or severe intestinal hemorrhage 1
• TPN is the mode of choice when emergency surgery is needed for complicated IBD 1

Administer nutritional support (parenteral or enteral, according to GI function) as soon as possible. 1

Preoperative Medication Management

Stop immunomodulators associated with anti-TNF-α agents as soon as possible before surgery (ideally 4 weeks preoperatively) to decrease risk of postoperative complications. 1 Preoperative treatment with immunomodulators combined with anti-TNF-α agents and steroids are risk factors for intra-abdominal sepsis in patients requiring emergency resectional surgery. 1

Monitoring and Escalation Timeline

If the patient's condition does not improve or deteriorates within 48-72 hours from initiation of medical therapy, second-line therapy or surgery must be considered. 1 Do not delay surgical consultation in critically ill patients. 1

For toxic megacolon specifically, surgery is mandatory if no clinical improvement and biological signs of deterioration occur after 24-48 hours of medical treatment. 1

Key Pitfalls to Avoid

• Never delay surgery in critically ill patients with toxic megacolon, perforation, or hemorrhagic shock 1
• Do not use antibiotics routinely—only for documented infection or abscess 1
• Avoid continuing immunosuppression without excluding C. difficile infection 1
• Do not continue medical therapy beyond 48-72 hours without reassessment for surgical intervention 1