What is the recommended treatment for a 45-year-old gentleman with chronic bloody diarrhea, abdominal pain, fecal incontinence, and significant weight loss, diagnosed with inflammatory bowel disease (IBD) unresponsive to steroids, mesalazine (Mesalamine), and antibiotics, with findings of colonic wall thickening and severely inflamed mucosa on CT and sigmoidoscopy?

From the Guidelines

The patient should undergo resection of the affected areas of the colon and rectum, as this is the most effective way to manage the chronic, progressive colonic disease that has been refractory to multiple medical therapies. This patient presents with a chronic, progressive colonic disease that has been refractory to multiple medical therapies including corticosteroids, mesalazine, and antibiotics. The histopathological findings of musculized capillaries, capillary fibroenthelial thrombi, and minimal mucosal inflammatory infiltrate are highly suggestive of ischemic colitis rather than inflammatory bowel disease or infectious colitis. The presence of a sigmoid stricture further supports this diagnosis.

Key Points to Consider

• The patient's symptoms, including bloody diarrhea, weight loss, and abdominal pain, have not improved with medical management, indicating the need for a more definitive treatment approach.
• The CT angiography showing patent arteries without vasculitis suggests that the ischemia is at the microvascular level rather than due to large vessel occlusion or vasculitis, making options like infliximab (for IBD) or corticosteroids with cyclophosphamide (for vasculitis) inappropriate.
• The negative TB testing and clinical picture make tuberculosis treatment unnecessary.
• According to the guidelines for the management of inflammatory bowel disease in adults 1, surgery should be considered for those who have failed medical therapy and may be appropriate as primary therapy in patients with limited ileal or ileo-caecal disease.
• More recent guidelines, such as the WSES-AAST guidelines for the management of inflammatory bowel disease in the emergency setting 1, also support the use of surgery in patients with complicated or refractory disease.

Treatment Options

• Option one, infliximab, is not recommended as the patient's symptoms and histopathological findings are not consistent with inflammatory bowel disease.
• Option two, isoniazide, rifampin, and ethambutol, is not recommended as the patient's TB testing is negative and the clinical picture does not suggest tuberculosis.
• Option three, corticosteroids and cyclophosphamide, is not recommended as the patient's symptoms and histopathological findings are not consistent with vasculitis.
• Option four, resection of the affected areas of the colon and rectum, is the most appropriate treatment option as it addresses the underlying cause of the patient's symptoms and has the potential to restore normal bowel function. Surgical resection would remove the damaged, strictured bowel and allow for restoration of normal bowel function, potentially resolving the patient's symptoms and preventing further complications such as perforation or complete obstruction.

From the Research

Treatment Options for Ulcerative Colitis

The patient's symptoms, such as bloody diarrhea, abdominal pain, and significant weight loss, are consistent with ulcerative colitis (UC) 2. Given the patient's lack of response to mesalazine, corticosteroids, and antibiotics, alternative treatment options should be considered.

Biologic Therapies

• Infliximab, a biologic therapy, has been shown to be effective in inducing and maintaining remission in patients with moderate to severe UC 3, 4.
• The use of infliximab as a first-line therapy, combined with corticosteroids, may be an effective approach in patients with acute severe UC and mucosal deficiency 5.

Other Treatment Options

• Corticosteroids, such as prednisone, can be effective in inducing remission in patients with mild to moderate UC, but are not recommended for long-term use due to adverse effects 6.
• Cyclophosphamide is not typically used as a first-line treatment for UC, and its use is usually reserved for patients with severe disease who have failed other treatments.
• Resection of the affected areas of the colon and rectum may be necessary in patients who do not respond to medical therapy or have complications such as toxic megacolon or colorectal cancer.

Recommended Treatment

Based on the available evidence, infliximab (option 1) may be a suitable treatment option for this patient, given its efficacy in inducing and maintaining remission in patients with moderate to severe UC. The use of isoniazide, rifampin, and ethambutol (option 2) is not recommended, as there is no evidence to suggest that the patient has tuberculosis. Corticosteroids and cyclophosphamide (option 3) may not be the best option, given the patient's lack of response to corticosteroids and the potential adverse effects of cyclophosphamide. Resection of the affected areas of the colon and rectum (option 4) may be necessary if the patient does not respond to medical therapy.