Management and long-term outcome of severe acute inflammatory bowel disease

Severe acute inflammatory bowel disease (SAIBD) poses several challenges to the clinician, who must recognize the severity of the flare, perform an accurate evaluation, and immediately select the most appropriate surgical and/or medical treatment. Once the diagnosis of inflammatory colitis is established, the severity of the flare should be assessed based on clinical and biochemical alterations that indirectly reflect the colonic involvement and, above all, on radiological and endoscopic visualization of the lesions. These investigations ensure identification of complications requiring emergency surgery (colonic perforation, colonic dilatation, severe bleeding). Patients without complications can be treated medically, under close supervision, with corticosteroid therapy (1 mg/kg/d), elimination of oral nutrition, and intravenous fluids and electrolytes. Surgery should be performed if this conservative approach fails; this is currently the most common situation in which surgery is performed in SAIBD. A third situation that requires surgery is occurrence of a relapse at discontinuation of the conservative treatment. Subtotal colectomy with ileostomy and sigmoidostomy is safe in emergency situations, ensures rapid recovery of a satisfactory general condition, supplies data of value for the etiologic diagnosis, and can be followed by any of the currently available techniques for restoring continuity: ileoanal anastomosis with reservoir (ulcerative colitis and indeterminate colitis) or ileorectal anastomosis (Crohn's disease) according to the condition of the rectum and anus, Iu the long-term, 80% of surgically-treated patients recover an unchanged body image and an acceptable to very satisfactory quality of life after an ileorectal or ileoanal anastomosis. Some patients, however, require a permanent ileostomy, particularly those with Crohn's disease diagnosed either during the acute episode or later, sometimes after an ileoanal anastomosis procedure.