AGA Clinical Practice Update on Inpatient Management of Adults With Inflammatory Bowel Disease: Expert Review.

Abstract

Patients with inflammatory bowel disease (IBD) often require hospitalization for medically refractory IBD or IBD-related complications. However, despite the increasing availability of effective medical therapies, inpatient IBD care remains challenging, as evidenced by the variation in hospital-acquired complications, delays in surgery, and high 30-day readmission rates. Therefore, this Clinical Practice Update Expert Review is intended to provide Best Practice Advice on the evaluation and management of hospitalized adult patients with IBD. We have developed Best Practice Advice statements to address 13 key clinical issues. This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the AGA Institute Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Prompt hospitalization should be considered for adult patients with IBD who present with severe disease refractory to outpatient treatment when there is high suspicion for an IBD-related complication, such as intestinal obstruction or intra-abdominal abscess, or when there is significant nutritional risk or failure to thrive. BEST PRACTICE ADVICE 2: The initial management of hospitalized adult patients with IBD should include supportive care. BEST PRACTICE ADVICE 3: The initial management of hospitalized adult patients with IBD should include an evaluation for IBD-related complications and concomitant infections. BEST PRACTICE ADVICE 4: Hospitalized adult patients with IBD should have their disease activity assessed with both biomarkers and endoscopic evaluation, when indicated. BEST PRACTICE ADVICE 5: Hospitalized adult patients with IBD should receive prophylactic anticoagulation for prevention of venous thromboembolism. BEST PRACTICE ADVICE 6: Hospitalized adult patients with severe ulcerative colitis should be counseled on the potential need for colectomy and should have a timely referral for surgical consultation. BEST PRACTICE ADVICE 7: Hospitalized adult patients with severe ulcerative colitis should receive initial treatment with intravenous corticosteroids at a methylprednisolone 60-mg daily dose equivalent. BEST PRACTICE ADVICE 8: Hospitalized adult patients with severe ulcerative colitis should be monitored for treatment response within 72 hours of medical treatment initiation. BEST PRACTICE ADVICE 9: Preparations should be made for initiating rescue therapy in hospitalized adult patients with severe ulcerative colitis who are not responsive to intravenous corticosteroid treatment. BEST PRACTICE ADVICE 10: In hospitalized adult patients with Crohn's disease and intestinal obstruction, medical treatment with intravenous corticosteroids should be considered when there is evidence of active inflammation. BEST PRACTICE ADVICE 11: In hospitalized adult patients with Crohn's disease and an intra-abdominal abscess, treatment should include infection control with abscess drainage (depending on size and location) and systemic antibiotics, as well as decision making regarding further medical or surgical management. BEST PRACTICE ADVICE 12: Hospitalized adult patients with Crohn's disease and active perianal symptoms should have a multidisciplinary treatment approach involving both medical and surgical care. BEST PRACTICE ADVICE 13: Stability of treatment response should be achieved before discharge, and a clear discharge transition plan established.