What is the recommended step‑by‑step management for a patient with inflammatory bowel disease presenting with bloody, mucoid discharge and mild‑to‑moderate disease activity?

Management of IBD with Bloody and Mucoid Discharge

For patients with inflammatory bowel disease presenting with bloody, mucoid discharge and mild-to-moderate disease activity, initiate immediate treatment with oral mesalamine 2.4-4.8 g daily for ulcerative colitis or oral corticosteroids (prednisolone 40 mg daily) for Crohn's disease, while simultaneously performing diagnostic evaluation to confirm disease type, extent, and exclude infectious causes. 1, 2

Initial Assessment and Stabilization

Clinical Evaluation

• Obtain detailed history including stool frequency and consistency, urgency, rectal bleeding severity, abdominal pain, fever, weight loss, and extraintestinal manifestations (joint, skin, eye symptoms) 1
• Perform physical examination checking for pulse rate, blood pressure, temperature, anemia, fluid depletion, abdominal tenderness or masses, and perineal examination 1
• Document recent travel, medications, smoking status, and family history 1

Laboratory Investigations

• Order complete blood count, urea and electrolytes, liver function tests, ESR or CRP, and albumin 1, 2
• Critical: Obtain stool cultures and Clostridium difficile toxin testing immediately, as C. difficile is more prevalent in IBD and associated with increased morbidity and mortality 2
• Consider additional testing for travel-related pathogens if indicated 1

Imaging

• Perform abdominal radiography to exclude colonic dilatation and assess disease extent 1
• Consider CT scan if clinical deterioration occurs or complications are suspected 1

Endoscopic Evaluation

Sigmoidoscopy/Colonoscopy Strategy

• For mild-to-moderate disease, perform colonoscopy to assess full disease extent, as this determines optimal therapy route 1
• Perform flexible sigmoidoscopy with rectal biopsy even if no macroscopic changes are visible 1, 2
• Look for loss of vascular pattern, granularity, friability, and ulceration in UC 1
• In suspected Crohn's disease, perform colonoscopy to terminal ileum with biopsy to document microscopic evidence 1

Common Pitfall: In moderate-to-severe disease, flexible sigmoidoscopy is safer than colonoscopy due to higher perforation risk—defer full colonoscopy until clinical improvement 1

Medical Management Based on Disease Type

For Ulcerative Colitis with Mild-to-Moderate Activity

• Start oral mesalamine 2.4-4.8 g (two to four 1.2-g tablets) once daily with food for induction of remission 3
• Swallow tablets whole; do not split or crush 3
• Ensure adequate fluid intake 3
• Evaluate renal function before initiation and periodically during therapy 3
• Once remission achieved, maintain with mesalamine 2.4 g daily 3

For Crohn's Disease with Mild-to-Moderate Activity

• For ileocolonic disease, start oral prednisolone 40 mg daily, tapering gradually over 8 weeks according to response 1
• Alternative: High-dose mesalamine 4 g daily may be sufficient for mild ileocolonic disease 1
• For isolated ileocecal disease with moderate activity, budesonide 9 mg daily is appropriate but marginally less effective than prednisolone 1

If Severe Disease Develops

Immediate escalation required if patient develops:

• Bloody stool frequency ≥6/day PLUS tachycardia >90/min, temperature >37.8°C, hemoglobin <10 g/dL, or ESR >30 mm/h 2

Management for acute severe colitis:

• Start IV corticosteroids immediately (hydrocortisone 100 mg four times daily OR methylprednisolone 40-60 mg daily) without waiting for stool culture results 4, 2
• Administer IV fluids with potassium supplementation of at least 60 mmol/day to prevent toxic dilatation 4, 2
• Initiate subcutaneous low-molecular-weight heparin for thromboprophylaxis—rectal bleeding is NOT a contraindication 4, 2
• Limit IV corticosteroid duration to maximum 7-10 days 4, 2

Monitoring and Response Assessment

Day 3 Assessment

• Evaluate clinical and biochemical response to IV corticosteroids 4
• Overall response rate to IV corticosteroids is 67%, with 33% requiring colectomy 2

For Non-Responders

• Consider medical rescue therapy with infliximab combined with thiopurine OR ciclosporin in multidisciplinary consultation 4
• Never extend IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery 4, 2

Surgical Indications

Emergency surgery is mandatory for: 1, 4, 2

• Hemodynamic instability despite resuscitation
• Colonic perforation with generalized peritonitis (radiological pneumoperitoneum and free fluid)
• Toxic megacolon complicated by perforation, massive bleeding, or clinical deterioration
• Persistent hemorrhagic shock non-responsive to resuscitation

Surgical procedure of choice: Subtotal colectomy with ileostomy for acute severe ulcerative colitis with massive hemorrhage or medical treatment failure 1, 4, 2

Critical Pitfalls to Avoid

• Never delay corticosteroid treatment in IBD patients while waiting for microbiology results—start empiric therapy immediately 4, 2
• Never delay surgery in critically ill patients with toxic megacolon—mortality increases significantly with perforation 4, 2
• Never extend IV corticosteroids beyond 7-10 days without escalation, as this carries no additional benefit 4, 2
• Do not perform colonoscopy in moderate-to-severe disease due to perforation risk—use flexible sigmoidoscopy instead 1
• Monitor for mesalamine-induced acute intolerance syndrome (cramping, acute abdominal pain, bloody diarrhea, fever)—this can mimic disease flare and requires immediate drug discontinuation 3

Maintenance Therapy

• For UC: Lifelong maintenance with aminosalicylates, azathioprine, or mercaptopurine to reduce relapse risk and potentially reduce colorectal cancer risk 1
• For Crohn's disease: Consider immunosuppressive therapy (azathioprine, 6-mercaptopurine, methotrexate) for maintenance, particularly given the incurable nature of CD 1