Hospital care for IBD gets practical refresh

AGA has released a clinical practice update examining how adults with inflammatory bowel disease (IBD) should be managed when they are hospitalized, with an emphasis on timely care, clear decision-making, and smoother transitions back to outpatient treatment.

“IBD care is growing more complex and IBD experts around the country are receiving many more calls from community gastroenterologists for advice treating their hospitalized patients,” corresponding author Shirley Cohen-Mekelburg, MD, of the Division of Gastroenterology and Hepatology at the University of Michigan, Ann Arbor, told GI & Hepatology News. “For example, 20 years ago, biologics were just becoming available, and most patients who were hospitalized with IBD were biologic naïve. We now have many more advanced therapies for IBD, indications for hospitalization are shifting as patients are more likely to be successfully treated for relatively serious symptoms in the outpatient setting, and patients who are hospitalized are more likely to be treatment-experienced.”

As Dr. Cohen-Mekelburg and coauthors Jana G. Hashash, MD, Edward V. Loftus, Jr., MD, and David T. Rubin, MD, note in their expert review published in Gastroenterology, patients admitted with ulcerative colitis or Crohn’s disease still face wide variation in testing, treatment, surgical timing, and discharge planning. These gaps contribute to complications and high 30-day readmission rates. The authors developed 13 best practice advice statements to address key clinical issues from hospital admission through discharge.

One key message is knowing when hospitalization is needed. Best practice advice statement 1 emphasizes that adults with IBD should be admitted promptly when severe symptoms do not respond to outpatient treatment, when complications such as bowel obstruction or abscess are suspected, or when there is significant malnutrition or failure to thrive. “This is a top best practice advice because it addresses the evolution of inpatient IBD care,” Dr. Cohen-Mekelburg said. “For example, it addresses updated indications for hospitalization including for severe disease refractory to outpatient treatment, serious complications, or nutritional needs that can’t be managed as well outside the hospital.”

According to the update, hospitalization allows faster evaluation and coordination among gastroenterologists, surgeons, radiologists, and dietitians. Once admitted, supportive care is foundational. This includes intravenous fluids, electrolyte replacement, treatment of anemia, and pain control. The authors emphasize avoiding opioids when possible and focus instead on treating the underlying inflammation or complication driving the pain. Screening for malnutrition and vitamin deficiencies is also highlighted, with early involvement of dietitians.

Infection testing is another early priority. According to the authors, symptoms that look like an IBD flare may be driven by infections, particularly Clostridioides difficile. Patients with worsening symptoms or poor response to steroids should also be evaluated for cytomegalovirus. Imaging plays a key role when obstruction, abscess, or toxic megacolon is a concern.

Early assessment of severity in patients with ulcerative colitis helps guide treatment. As outlined in the update, blood tests such as C-reactive protein, along with endoscopic evaluation when appropriate, help determine how aggressive therapy needs to be. Intravenous corticosteroids remain the standard initial treatment for severe disease, with close monitoring over the first 72 hours. Lack of improvement by day three should trigger planning for rescue medical therapy or surgery.

The update also highlights the importance of preventing blood clots. Hospitalized patients with IBD have about double the risk of venous thromboembolism compared with other patients, and routine preventive anticoagulation is recommended unless there is a clear contraindication.

For Crohn’s disease, management depends heavily on the complication driving admission. As noted in the update, obstruction related to active inflammation may respond to medical therapy, while abscesses usually require antibiotics and drainage, often with input from surgeons and interventional radiologists. Perianal disease is best managed with a combined medical and surgical approach.

Finally, the authors frame discharge planning as part of treatment, not as an afterthought. As best practice advice statement 13 reads: “Stability of treatment response should be achieved before discharge, and a clear discharge transition plan established.” According to Dr. Cohen-Mekelburg, who also directs the Inflammatory Bowel Disease Program at VA Ann Arbor Healthcare System, this statement stands out as especially relevant to daily clinical practice “because it addresses the full inpatient journey, including hospital discharge, where many questions often arise about timing of discharge or transition to outpatient care,” she said.

Where evidence was limited, the update reflects a combination of published data and the authors’ clinical experience. “We realized that while institutions differ in their resources and policies, we generally follow a similar approach to inpatient IBD care,” Dr. Cohen-Mekelburg said. “We had more deliberation in making sure we were acknowledging specific scenarios that we are faced with more frequently such as the role of JAK inhibitors for treatment of ulcerative colitis in the inpatient setting or the role of venous thromboembolism prophylaxis on discharge home.”

Dr. Cohen-Mekelburg reported having no disclosures. Other authors reported serving as advisors or consultants to, or receiving research support from, several pharmaceutical companies.