Inflammatory Bowel Disease (IBD)

Objectives

To guide the immediate assessment and management of Inflammatory Bowel Disease in deployed operational environments.

Scope

Addresses initial and advanced management of confirmed or suspected IBD presentations in a deployed setting. It does not cover detailed management requiring specialist gastroenterology input beyond immediate stabilisation. 

Audience

This guideline is intended for use by registered healthcare professionals fulfilling a general role in forward medical locations or in an emergency department in a deployed hospital setting.

Initial Assessment & Management

Presentation

An acute flare of IBD may occur in those known to have IBD, or as a de-novo presentation.  It typically manifests with several weeks of cramping lower-abdominal pain, urgent loose stools often mixed with blood or mucus, and potentially unintentional weight loss despite maintained appetite.  Extra GI symptoms like fatigue, low-grade fevers, aphthous mouth ulcers or large-joint pain may accompany the bowel disturbance.  

The course is typically insidious and relapsing rather than abrupt, although fairly rapid onset symptoms are possible.  It’s critical to distinguish this presentation from infectious or traveller’s diarrhoea, which usually begins acutely within hours of exposure to a pathogen, tends to be watery, is more often accompanied by vomiting, and typically settles within a week.  A history of contacts with similar presentations strongly supports infection.  Please see Traveller’s Diarrhoea CGO for further information.  

Failure to improve after 48–72 h of rehydration and empirical antimicrobials, persistent nocturnal symptoms, rectal bleeding, or persistently raised inflammatory markers with negative stool cultures should prompt consideration of inflammatory bowel disease and onward specialist referral. 

Initial Management (Role 1 & Initial Role 2/3 Assessment) 

  • Ensure infective causes (e.g., traveller’s diarrhoea, malaria) are excluded. 
  • take history and clearly document clear timeline of symptoms, stool description, weight change, and any extra-intestinal features.

    Identify severity.  The following are suggestive of a severe flare:

    • ≥6 bowel movements/day 
    • Blood in stool
    • Fever, tachycardia, anaemia (Hb <105), CRP >30
    • Signs of bowel obstruction 

Supportive management

  • Hydration; oral preferred, intravenous sodium chloride if not tolerated. Escalate to role 2 as dys-electrolytaemia highly likely in this context.
  • Encourage oral food intake; avoid fasting unless obstruction suspected, which would be treated as per bowel obstruction. 
  • Avoid NSAIDs for abdo pain (may worsen IBD, and potentially nephrotoxic if dehydrated).
    Opioid with caution as slowing transit time may increase the risk of toxic megacolon.
    Paracetamol for pain.
  • Loperamide contraindicated if blood in stool or systemic symptoms.

 

Observation & Monitoring

    • Bowel chart for frequency and presence of blood in stool
    • temperature
    • heart rate
  • Watch for escalation to severe criteria (tachycardia, fever, Hb drop, CRP >30).
  • Early telemedicine consult with gastroenterology .
  • Prepare for evacuation if deterioration or severe flare suspected.

Mild disease: in those known to have IBD, currently managed on Mesalazine and has available dose:

  • Double dose Mesalazine (up to 3 months)

If new diagnosis treatment is supportive as above

Severe disease - evacuation to next level of care: 

  • Steroids; IV Hydrocortisone 100 mg QDS (or 60mg oral prednisolone if IV route not available).  Evacuation to deliver IV hydrocortisone is the preferred option.
  • IV Co‑amoxiclav 1.2 g TDS (per antimicrobial guidance)
  • LMWH for VTE prophylaxis 
Biologics: Increasingly, patients may be undergoing treatment with biologic therapy. This would be less common in deployed personnel particularly if cold chain reliant.  Crucially, there would be no deviation from management above: exclude infection, commence steroids.  Their biologic should be continued. 

Advanced Assessment & Management

At role 2, stool cultures should be sent in conjunction with stool PCR to exclude infectious causes

  • Hydration & Electrolyte Correction
    • Oral rehydration preferred; IV fluids if unable to maintain intake.
    • Monitor for hypokalaemia (common with diarrhoea)
  • Observation & Monitoring
    • Daily vitals as at role 1, stool frequency, hydration status.
    • Serial CRP, FBC, renal panel, electrolytes
    • Watch for escalation to severe criteria (tachycardia, fever, Hb drop, CRP >30).
    • Reach-back & Evacuation Planning
    • Prepare for evacuation if deterioration or severe flare suspected.
  • Abdominal X‑ray to exclude toxic megacolon
    • Severe abdominal pain and positive radiographic findings necessitate involvement of the general surgical team and discussion with specialists in the UK.
  • Ongoing liaison with gastroenterology via reach‑back
  • Continue IV corticosteroids (Hydrocortisone 100 mg QDS), switching to prednisolone 40mg following clinical improvement, eating and drinking.  
  • Serial abdominal exams and imaging to monitor response
  • Regular bloods: CRP, FBC, renal panel, electrolytes 

Prolonged Casualty Care

  • Maintain IV hydration and electrolyte balance
  • Continue corticosteroids and antibiotics. In practice corticosteroids tend to be tapered over ~6 weeks but this should be guided by specialist input and is unlikely to take place in the deployed setting.  
  • Frequent reassessment with history, examination and available imaging as available for toxic megacolon, perforation or bleeding 

Last reviewed: 16/02/2026

Next review date: 16/02/2027

References

NICE NG129 (IBD)