Abdominal pain and diarrhea with or without occult blood are the most common symptoms at presentation The pain is often colicky and occurs soon before or during bowel movements in UC In Crohn disease, given possible ileal involvement, the abdominal pain may localize to the right lower quadrant The abdominal examination may elicit guarding and rebound tenderness prompting consideration of acute appendicitis in the differential diagnosis Eliciting a history of chronic symptoms and identification of inflammation of other portions of intestine beyond the appendix alone during the evaluation may aid in differentiating IBD from appendicitis IBD occasionally causes massive upper or lower GI bleeding due to intestinal mucosal breakdown and potential involvement of blood vessels underneath Rarely, due to the ability of Crohn disease to cause fibrostenosing inflammation, children may present with complete intestinal obstruction Partial obstruction from significant intraluminal narrowing from stricturing disease, often in the ileum, is more common Children with Crohn disease may develop intra-abdominal abscesses or fistulae due to the transmural nature of the inflammation The presence of significant abdominal distention, accompanied by diminished or absent bowel sounds, should raise the suspicion of actual or impending perforation, even in the absence of severe pain Perforation may occur even after minor abdominal trauma and must be ruled out when patients with known IBD complain of abdominal pain after trauma The development of massive colonic distention, termed toxic megacolon, is a rare complication of both UC and Crohn disease Toxic megacolon represents a life-threatening emergency that has a reported mortality rate of as high as 25% Although rare in children, up to half of the cases occur with the first attack of IBD; another 40% are seen in patients receiving high-dose steroid therapy for fulminant colitis Toxic megacolon almost always involves the transverse colon The pathophysiology is believed to be an extension of the inflammatory process through all layers of the bowel wall, with resulting microperforation, localized ileus, and loss of colonic tone The result is imminent major perforation, peritonitis, and overwhelming sepsis Antecedent barium enema, opiates, or anticholinergics may all precipitate toxic megacolon Clinical features include (i) a rapidly worsening clinical course usually associated with fever, malaise, and even lethargy; (ii) abdominal distention and tenderness usually developing over a few hours or days; (iii) a temperature of 38.5°C (101.3°F) or higher and a neutrophilic leukocytosis; and (iv) an abdominal radiograph showing distention of the transverse colon of more than to cm In a recent case-control study of children with toxic megacolon, fever, tachycardia, dehydration, and electrolyte abnormalities were significantly more common than in age-matched controls with UC without toxic megacolon The differential diagnosis of acute fulminant colitis includes acute bacterial enteritis, amebic dysentery, ischemic bowel disease, and radiation colitis Other potential clinical manifestations of IBD related to extraintestinal complications include thrombosis of cerebral, retinal, or peripheral vessels that may lead to coma, seizures, or focal visual or motor deficits; gallstone cholecystitis; renal calculi leading to hematuria; and pancreatitis Pancreatitis, in particular, should be considered in an IBD patient on thiopurine maintenance therapy Triage Children with initial presentations of significant GI hemorrhage, toxicity from toxic megacolon, severe dehydration or perforation will be triaged rapidly with standard triage protocols Children with known IBD presenting with symptoms of a flare (e.g., abdominal pain and diarrhea) with a fever should be evaluated more promptly The differential includes infectious etiology (e.g., C difficile ), toxic megacolon, or intra-abdominal abscess (more so in Crohn disease) C difficile in particular has become a significant clinical challenge in children with IBD with increased amounts of colonization and infection being reported Children with signs of orthostasis, dehydration, significant abdominal pain, or active lower GI bleeding may also need to be evaluated promptly Initial Assessment/H&P At presentation, the emergency provider should focus on obtaining a detailed medical history including family probing for any potential new diagnoses of IBD Physical examination should include ophthalmic, skin, joint, and perianal evaluation in addition to a comprehensive abdominal examination In those with an established diagnosis of IBD, medication compliance and identification of medications used for the disease should be completed, particularly those which are immunosuppressive (e.g., steroids) The H&P should also be directed to identify other potential etiologies other than IBD associated with painful rectal bleeding including intussusception, Henoch–Schönlein purpura (HSP), and hemolytic uremic syndrome (HUS) Management/Diagnostic Testing Abdominal radiography, including an upright view, is indicated in cases of suspected partial or full obstruction, toxic megacolon, or perforation Abdominal ultrasound is the preferred initial modality to evaluate for an abscess, and has a sensitivity approaching 90% and specificity approaching 100% to identify bowel inflammation Computed tomographic (CT) imaging should be used sparingly and only if urgent information related to inflammation or a possible extraenteric complication is needed, as children with IBD have been identified as having moderately increased exposure to radiation over the course of their chronic disease MRI enterography has gained favor as an alternative imaging technique when delineation beyond ultrasound is desired It may be completed once the child is admitted or in the outpatient setting Laboratory Testing Laboratory evaluation should include a CBC with differential, chemistry panel (chem 10, especially in those with chronic diarrhea or vomiting), liver panel (albumin, protein, aminotransferases, bilirubin), erythrocyte sedimentation rate (ESR), C-reactive protein, amylase, and lipase ESR is elevated in up to 80% of patients with newly diagnosed Crohn disease and in 60% of those with newly diagnosed UC It may also be used to assess the efficacy of therapies in those with previously diagnosed IBD A blood type and crossmatch is indicated in cases of suspected or confirmed severe anemia Stool testing for C difficile, stool culture, as well as ova and parasites should be obtained Increasingly, fecal calprotectin, a protein produced by neutrophils, is being used to help diagnose IBD and monitor the severity of inflammation in those with established disease Management Management is guided by the history, physical, and diagnostic testing The role of the ED provider is to provide supportive care while ensuring a significant medical complication (e.g., significant dehydration, electrolyte imbalance, severe anemia, superinfection) or potential complication requiring surgical intervention (e.g., toxic megacolon, intraabdominal or perirectal abscess, perforation) is identified and addressed if present Initial supportive medical care includes rehydration with crystalloid per established protocols Blood transfusions may be required in those with severe anemia If toxic megacolon or perforation is suspected, arrangements should be made for admission to an intensive care unit (ICU) and for surgical consultation A nasogastric (NG) tube should be placed Patients should be started on aggressive doses of broad-spectrum antibiotics such as piperacillin/tazobactam Suitable alternative therapies may include ampicillin/sulbactam, or cefoxitin in combination with gentamicin Management of significant GI bleeding should be performed as described in Chapter 33 Gastrointestinal Bleeding Emergency management of suspected intestinal obstruction includes gastric decompression with NG drainage and IV rehydration, initially with normal saline Prompt surgical consultation is required in cases of perforation or toxic megacolon Concomitant consultation by a pediatric gastroenterologist and surgeon may be indicated with identification of an intra-abdominal or perirectal abscess, fistulizing disease, and partial or complete obstruction to coordinate care during an admission Clinical Indications for Discharge or Admission The diagnosis of IBD is based on a combination of clinical, pathologic, and radiologic data In those cases where a medical or surgical emergency is not identified, and diagnostic testing has been completed or started (e.g., stool infectious workup), then discharge of a child with suspected IBD with close follow-up by a pediatric gastroenterologist is appropriate Further diagnostic studies such as esophagogastroduodenoscopy, colonoscopy, or GI contrast studies can be arranged on an outpatient basis The initiation of therapies such as corticosteroids, aminosalicylic acid compounds (e.g., mesalamine), immunomodulators (e.g., 6-mercaptopurine), or biologics (e.g., infliximab) can started on an outpatient basis, often after confirmation of the diagnosis Psychosocial factors such as concern for possible negligence by the child’s guardians, poor history of follow-up, or significant abdominal pain which cannot be managed at home, may also result in hospital admission Patients with known IBD who are deemed to have mild to moderate flares may only require adjustments of their IBD maintenance regimen and can be discharged from the ED with close follow-up with their gastroenterologist Severe anemia with ongoing significant blood loss requiring red blood cell transfusion, failure to maintain adequate hydration, electrolyte imbalances requiring rehydration and replacement, and severe failure to thrive are indications for supportive care and admission Those children with suspected IBD or known IBD in whom a significant medical or surgical manifestation has occurred should be admitted to the appropriate care setting Children with suspected severe colitis and frequent bloody bowel movements but with ... surgical emergency is not identified, and diagnostic testing has been completed or started (e.g., stool infectious workup), then discharge of a child with suspected IBD with close follow-up by a pediatric. .. significant GI bleeding should be performed as described in Chapter 33 Gastrointestinal Bleeding Emergency management of suspected intestinal obstruction includes gastric decompression with NG... consultation is required in cases of perforation or toxic megacolon Concomitant consultation by a pediatric gastroenterologist and surgeon may be indicated with identification of an intra-abdominal