Practical summaries of assessment, investigations, management and medications for everyday gastroenterology care.
BSG acute upper GI bleeding care bundle
The BSG-led multisociety care bundle for the first 24 hours of acute upper gastrointestinal bleeding. The original one-page document is displayed below.
Open the care bundle PDF full size · BSG source and supporting publication
Acute colitis admission management guide
ADMIT-ASC score (Admission Model for Intensification of Therapy in Acute Severe Colitis)
CRP ≥ 100 mg/L = 1 pt • Albumin ≤ 25 g/L = 1 pt • UCEIS 4–6 = 1 pt, ≥ 7 = 2 pts → total 0–4
Use this bedside score on the day of admission for any adult meeting Truelove & Witts criteria for acute severe ulcerative colitis before starting IV hydrocortisone. It needs only routine admission bloods and the UCEIS from the mandatory flexible sigmoidoscopy, so there’s no extra cost or delay.
- Score 0 → steroid response almost certain – continue standard 3-day course.
- Score 1–2 → ~25–45 % risk of failure – monitor closely and still apply day-3 Oxford criteria.
- Score ≥ 3 → 84–100 % chance of steroid non-response – flag for immediate rescue therapy discussions (infliximab / ciclosporin) and alert colorectal surgery on admission.
Early identification (48–72 h sooner than traditional day-3 rules) short-circuits delays, reduces emergency colectomies, and supports clear shared decision-making.
For new patients admitted with suspected IBD (Crohns or UC)
Cyclic vomiting syndrome: acute episode
How to abort the acute vomiting phase?
Drugs used in the treatment of cyclic vomiting syndrome, and their suggested dosages.
Setting: Terminating the acute episode.
Sumatriptan
- Intranasally: 20 mg as a single dose, maximum dose of 40 mg per day.
- Subcutaneous: 6 mg as a single dose, maximum dose of 12 mg per day.
Lorazepam
0.5–2 mg up to four times daily.
Ondansetron
8 mg three times daily.
Source as cited on the supplied teaching slide: Ford A, Neurogastroenterol Mot 2018.
Confirm dosing, route and suitability against current local prescribing guidance before clinical use.
Resident Doctor quick reference section made by BSG :
Medications used in Gastroenterology – quick reference guide
Commonly used drugs in gastroenterology reference guide (not for clinical use, please cross reference.)- by Dr Ben McCleod.
Biologics dosage & monitoring for IBD
Interactive IBD Drugs Cheat Sheet
This section reflects ECCO guidance and common clinical practice adopted with permission from Dr B Gros. Always confirm specifics with local guidelines. This summary is not a replacement for the comprehensive ECCO/BSG guidelines.
General ECCO‑Based Recommendations & Monitoring
ECCO guidelines emphasize baseline and ongoing checks before and during advanced therapy:
- Screen for infections: TB (IGRA or skin test + CXR), hepatitis B/C, HIV, varicella (± EBV if relevant).
- Update vaccinations: Influenza, pneumococcal, COVID‑19, and others before immunosuppression.
- Regular labs: FBC, LFT, renal function at set intervals.
- Match therapy to disease severity/location and your patient’s comorbidities.
- Use ECCO algorithms for step‑up or top‑down decisions.
5‑ASA (Mesalazine) Agents
- Induction Dose: ≥ 2 g/day up to 4.8 g/day
- Maintenance Dose: ≥ 2 g/day
- Route: Oral or topical
- Monitoring: Renal function checks
- ECCO Note: Best for mild–moderate UC; topical for left‑sided disease.
Thiopurines (Azathioprine, Mercaptopurine)
- Induction: Not for rapid induction
- Azathioprine Maintenance: 1.5–2.5 mg/kg/day
- Mercaptopurine Maintenance: 0.75–1.5 mg/kg/day
- Monitoring: FBC, LFT; TPMT testing first
- ECCO Note: Watch for myelotoxicity, especially with combination therapy.
Methotrexate
- Induction: 25 mg IM weekly (rarely alone for rapid induction)
- Maintenance: 15 mg IM weekly
- Monitoring: CBC, LFT, renal function
- Folic Acid (UK): 5 mg once weekly, on a different day
- ECCO Note: Supplement folate; monitor for liver fibrosis.
Anti‑TNF Agents (Infliximab, Adalimumab, etc.)
- Infliximab (IV): 5 mg/kg at 0, 2, 6 weeks, then every 8 weeks
- Adalimumab (SC): 160/80 mg at 0, 2 weeks, then 40 mg every 2 weeks
- Monitoring: Standard infection screening and vaccine update
- ECCO Note: Combine with immunomodulators to cut immunogenicity; infection risk rises.
Anti‑Integrin (Vedolizumab)
- Vedolizumab IV: 300 mg at 0, 2, 6 weeks, then every 8 weeks
- Vedolizumab SC: 108 mg every 2 weeks
- Monitoring: TB, viral hepatitis, HIV; check response by week 14
- ECCO Note: Gut‑selective; for moderate–severe UC or CD after other therapy.
IL‑12/23 & IL‑23 Inhibitors (Ustekinumab, Risankizumab, Mirikizumab, etc.)
- Ustekinumab: IV induction (weight‑based), then SC 90 mg every 8–12 weeks
- Risankizumab: IV 600 mg at 0, 4, 8 weeks (Crohn’s), then SC 360 mg every 8 weeks
- Mirikizumab: 300 mg IV at 0, 4, 8 weeks (UC; 900 mg for CD), then from week 12 SC 200 mg (UC) or 300 mg (CD) every 4 weeks
- Monitoring: CBC, LFT, TB screen; infection checks
- ECCO Note: Works in moderate–severe disease; option after anti‑TNF failure.
JAK Inhibitors (Tofacitinib, Filgotinib, Upadacitinib)
- Tofacitinib: 10 mg BD induction, 5 mg BD maintenance
- Filgotinib: 200 mg daily
- Upadacitinib: 45 mg daily induction, then 15–30 mg daily maintenance
- Monitoring: Lipids, FBC, LFT; watch infection risk (herpes zoster)
- ECCO Note: Rapid onset; check CV and thrombotic risks.
S1P Receptor Modulators (Ozanimod, Etrasimod)
- Ozanimod: Titrate 0.23 mg → 0.46 mg → 0.92 mg daily
- Etrasimod: 2 mg daily
- Monitoring: Heart rate, ECG, LFT
- ECCO Note: Reduces lymphocyte trafficking; screen cardiac conduction.
References
Resource: ibd-eii.com/ibdcheatsheet
DOI: 10.5281/zenodo.13624693
Disclaimer
Common Scenarios and investigations to order
GI Bleeds
Blood Tests: Daily FBC, U+E every other day for 5 days or until no bleeding.
Monitoring: Stool charts for all patients.
Acute Colitis
Stool Tests: Send for cultures, C. difficile toxin, and maintain stool charts.
Bloods: FBC, U+E, LFTs, CRP daily. Include Mg, Ca, and PO4 if major nutritional issues. For new patients pre biologic screen including TPMT.
Imaging: Erect CXR and AXR as needed to exclude toxic dilatation (consult SpR for frequency).
Refeeding Syndrome
Monitoring: Daily U+E, Ca, PO4, and Mg until stable.
Parenteral Nutrition: Daily monitoring (FBC, U+E, Mg, Ca, PO4, LFTs, CRP) if unstable, twice weekly once stable.
Non-invasive liver screening (liver aetiology screen)
Scope. Summary of the liver aetiology screen for patients with non-acute abnormal liver blood tests, adapted from the BSG guideline (2018). Provided for education. Check the current guideline and follow your local pathway.
When to use it. For non-acute abnormal liver blood tests. In most situations perform only the standard panel. Reserve the extended panel for patients in whom the standard panel shows no clear cause.
Adults: standard aetiology screen
- Abdominal ultrasound
- Hepatitis B surface antigen
- Hepatitis C antibody, with follow-on PCR if positive
- Anti-mitochondrial antibody
- Anti-smooth muscle antibody
- Antinuclear antibody
- Serum immunoglobulins
- Simultaneous serum ferritin and transferrin saturation
Children: how it differs
- Ferritin and transferrin saturation may not be indicated
- The autoantibody panel should include anti-liver kidney microsomal (anti-LKM) antibody and coeliac antibodies
- Alpha-1-antitrypsin level and caeruloplasmin (age over 3 years) should be included. Discuss any abnormality with an appropriate inherited metabolic disease specialist.
Standard versus extended panel by suspected cause
Liver aetiology table for patients with non-acute abnormal liver blood tests
| Suspected cause | Standard panel | Extended panel |
|---|---|---|
| Viral hepatitis | Standard panelHepatitis B surface antigen AND hepatitis C antibody, with follow-on PCR if positive | Extended panelAnti-HBc and anti-HBs; hepatitis B DNA; quantification of hepatitis delta in high-prevalence areas |
| Iron overload | Standard panelFerritin AND transferrin saturation | Extended panelHaemochromatosis gene testing |
| Autoimmune liver disease (excluding PSC) | Standard panelAnti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, serum immunoglobulins | Extended panelAnti-LKM antibody and coeliac antibodies. Consider ANCA in the presence of cholestatic liver blood tests. |
| Metabolic liver disease | Standard panelNot included in the standard panel | Extended panelAlpha-1-antitrypsin level; thyroid function tests; caeruloplasmin (age over 3 and under 40 years) ± urinary copper collection |
ANCA, antineutrophil cytoplasmic antibodies; LKM, liver kidney microsome; PCR, polymerase chain reaction; PSC, primary sclerosing cholangitis.
Source. Adapted from Table 2 in Newsome PN, et al. Guidelines on the management of abnormal liver blood tests. Gut 2018;67:6–19. doi:10.1136/gutjnl-2017-314924.
Procedures
Post-ERCP
Monitoring: If pain-free and NEWS normal, no bloods required. If in pain, perform FBC, U+E, LFT, CRP, and amylase. Consider urgent CT (perforation) and surgical review.
Post-EUS/Other Therapies
If pain-free and mobilizing, no bloods required. If in pain or NEWS abnormal, manage like post-ERCP (omit amylase).
Gastroscopy/OGD
Fasting: Minimum 4 hours, ideally nil by mouth from midnight for morning lists or light breakfast for afternoon lists.
Urgency: Urgent requests should be delivered directly to the endoscopy unit and discussed with the endoscopy sister/nurse in charge.
Consent: Completed by the scoping clinician in the endoscopy department.
Colonoscopy
Bowel Prep: Moviprep (specific timing depending on morning/afternoon list). Stop ferrous sulfate 1-2 weeks before.
Antiplatelets/Anticoagulants: Check with seniors about stopping these drugs before the procedure if therapeutic interventions (e.g., polypectomy) are planned.
ERCP/EUS
Fasting: As per OGD guidelines.
Bloods: FBC, U+E, LFTs, clotting, and Group and Save.
Consent: Taken by SpR or consultant.
Anticoagulants and antiplatelets before elective ERCP/EUS
Low bleeding risk: diagnostic EUS without sampling, or biliary stenting without sphincterotomy
Continue aspirin and P2Y12 antiplatelets, such as clopidogrel.
Continue warfarin. Check the INR is within its therapeutic range during the preceding week.
Omit the morning DOAC dose on the procedure day.
High bleeding risk: sphincterotomy, EUS-guided sampling or therapeutic EUS
If thrombotic risk is low:
Continue aspirin.
Stop P2Y12 antiplatelets seven days before.
Stop warfarin five days before. Confirm INR below 1.5 before the procedure.
Take the last DOAC dose three days before.
For dabigatran with creatinine clearance of 30–50 mL/min, take the last dose five days before.
Patients at high risk of thrombosis
Arrange a specialist plan before stopping treatment. Some patients taking warfarin need heparin bridging. Do not routinely bridge DOACs. Seek interventional cardiology advice for patients with coronary stents, including those taking anticoagulation alone.
Restarting treatment
Document the restart plan before discharge. Warfarin can usually restart that evening. After high-risk procedures, DOACs generally restart after 48–72 hours, once haemostasis is secure. Individualise antiplatelet restarting and any bridging plan.
Ampullectomy requires a separate assessment of whether to continue aspirin.
Based on BSG/ESGE guidance and its 2024 addendum.
Intestinal Failure Patients
Key Notes: Do not handle central lines; only trained staff manage them to avoid infections.
Bloods on Admission: FBC, U+E, LFT, clotting, CRP, Mg, bone profile, B12, folate, and Vitamin D.
Monitoring: Fluid balance, electrolyte levels, and nutritional status. Address high stoma outputs with TPN adjustments, fluid restriction, and medications (e.g., loperamide, codeine, PPIs).
Liver Procedures
Bloods: FBC, U+E, LFTs, clotting, Group and Save.
Consent: Registrar or consultant only.
Pre-Procedure Management: Confirm antiplatelets/anticoagulants are stopped. Vitamin K, platelets, or FFP may be needed for coagulation support.
Specific Procedures:
Liver Biopsy: Consider plugged or transjugular biopsy if clotting is abnormal.
TACE/TIPSS: Requires antibiotics pre- and post-procedure, adequate hydration, and coagulation correction if needed.
Other useful websites
Useful links & resources:
UK Acute Upper GI Bleeding bundle https://www.bsg.org.uk/wp-content/uploads/2019/12/Fig-1-Summary-AUGIB-care-bundle.pdf
BSG Decompensated Cirrhosis Care Bundle video https://www.bsg.org.uk/clinical-resource/bsg-decompensated-cirrhosis-care-bundle/
Gastroenterology/Nutrition
BSG Investigation of Chronic Diarrhoea in adults:
https://www.bsg.org.uk/clinical-resource/guidelines-for-the-investigation-of-chronic-diarrhoea-in-adults-bsg-3rd-edition/
NICE guidance on Ulcerative Colitis https://www.nice.org.uk/guidance/ng130
A practical approach to the management of high-output stoma https://fg.bmj.com/content/5/3/203
The Northern Gut Hub