Acute Severe IBD & Inpatient Management

Sigmoidoscopy without bowel prep within 48h is essential — bowel prep can trigger perforation in severely inflamed colon. Use an unprepped exam to confirm Mayo 3 and biopsy for CMV.

VTE prophylaxis with LMWH is MANDATORY in ASUC — IBD inflammation creates a hypercoagulable state and rectal bleeding is NOT a contraindication. Many junior teams still get this wrong.

Oxford criteria are the most validated day-3 decision tool — apply them rigorously and do not delay rescue or surgery decisions beyond day 5.

Sequential rescue (CSA then IFX or vice versa) is associated with high morbidity and mortality — if the first rescue fails at days 5-7, go to colectomy.

Cultural counseling about ostomy and prayer hygiene (taharah) is essential in Saudi practice — patients deserve explicit guidance about ablution and prayer with an ostomy.

Embed your ASUC protocol as an order set in your hospital HIS — this ensures every junior doctor follows the right sequence and the protocol becomes auditable.

Endoscopic balloon dilation works best for short, straight, post-anastomotic strictures — long, angulated, or pre-stenotic dilation typically need surgery.

Never start a biologic with an active untreated intra-abdominal abscess — drain first, control infection, then biologic. Starting biologic with active abscess can be catastrophic.

SGA provides remote MDT consultation for complicated CD cases — community gastroenterologists can submit cases via the SGA portal for tertiary input.

In any IBD flare not responding to standard therapy, biopsy for CMV — CMV reactivation is underdiagnosed and a treatable cause of refractory inflammation.

A "responder" still needs a discharge plan with maintenance therapy and follow-up — the same flare will likely recur within 12 months without escalation.

In severe ASUC with low albumin, accelerated IFX dosing (10 mg/kg or shortened intervals) overcomes the increased clearance — single 5 mg/kg dose fails in this group.

When IFX rescue fails, proceeding to colectomy ON THAT ADMISSION (rather than discharging and returning) reduces 90-day mortality 4-fold.

Toxic megacolon mortality goes from 5% to 30% with even 24h surgical delay — call colorectal surgery the moment you suspect it, not after the AXR confirms.

Document VTE prophylaxis in every IBD admission — Saudi quality metrics now include this; missing it triggers audit flags.

Patients discharged after ASUC or IBD surgery should receive 4 weeks of LMWH prophylaxis at home — not just inpatient — yet most Saudi hospitals stop at discharge.

Start enteral nutrition within 48h via NG tube — even in ASUC, gut feeding maintains barrier integrity and reduces infection.

A standardized MDT memo distributed within 48h is what turns an MDT meeting into actionable patient care — without it, decisions are forgotten.

When the day-5 reassessment shows IFX failure, the colectomy decision should be documented and surgery booked the SAME DAY — no further trials.

For refractory complex perianal fistulae after IFX, Cx601 (darvadstrocel) stem cell therapy is FDA/EMA-approved — discuss availability with Saudi MOH and consider compassionate use.

SCENIC guidelines reshaped dysplasia management — most visible lesions can be resected endoscopically rather than triggering colectomy.