What is the initial treatment approach for a patient with ileocolitis?

Initial Treatment Approach for Ileocolitis

For patients with mild to moderate ileocolitis, high-dose mesalazine (4 g/day) is the appropriate initial therapy, while oral corticosteroids such as prednisolone 40 mg daily should be used for moderate to severe disease or for those who fail to respond to mesalazine. 1

Assessment of Disease Severity

Before initiating treatment, it's crucial to assess the severity of ileocolitis:

• Mild disease: Fewer than 4 bowel movements per day, minimal abdominal pain, no systemic symptoms
• Moderate disease: 4-6 bowel movements per day, moderate abdominal pain, mild systemic symptoms
• Severe disease: More than 6 bowel movements per day, severe abdominal pain, systemic symptoms (fever, weight loss)

Treatment Algorithm Based on Disease Severity

Mild Ileocolitis

1. First-line: High-dose mesalazine (4 g/day) 1

   • Monitor for clinical response within 2-4 weeks
   • Continue if effective for maintenance therapy

2. If no response to mesalazine:

   • Advance to oral corticosteroids (see moderate disease)

Moderate to Severe Ileocolitis

1. First-line: Oral prednisolone 40 mg daily 1

   • Taper gradually over 8 weeks according to clinical response
   • More rapid reduction is associated with early relapse

2. Alternative for isolated ileo-cecal disease:

   • Budesonide 9 mg daily (slightly less effective than prednisolone but fewer side effects) 1

3. Adjunctive therapies:

   • Elemental or polymeric diets can be used as adjunctive therapy 1
   • Total parenteral nutrition may be appropriate in complex, fistulating disease 1

Severe Ileocolitis with Complications

1. Intravenous steroids: Hydrocortisone 400 mg/day or methylprednisolone 60 mg/day 1

   • Consider concomitant IV metronidazole to distinguish between active disease and septic complications

2. Monitoring requirements:

   • Vital signs four times daily
   • Stool chart recording frequency and characteristics
   • Laboratory tests every 24-48 hours (CBC, ESR/CRP, electrolytes, albumin, liver function)
   • Abdominal imaging if deterioration occurs

3. Surgical consultation: Consider early surgical consultation for patients with severe disease 1

Special Considerations

Fistulating Disease

• Metronidazole 400 mg three times daily and/or ciprofloxacin 500 mg twice daily for simple perianal fistulae 1
• Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day for persistent fistulae 1
• Infliximab (5 mg/kg) for refractory fistulae 1, 2

Intestinal Obstruction

• Surgery is mandatory for symptomatic intestinal strictures that don't respond to medical therapy 1
• Any colorectal stricture should be assessed with endoscopic biopsies to rule out malignancy 1

Maintenance Therapy

After achieving remission, maintenance therapy should be initiated:

• Aminosalicylates, azathioprine, or mercaptopurine are recommended to reduce risk of relapse 1
• Lifelong maintenance therapy is generally recommended for all patients 1

Common Pitfalls and Caveats

1. Delayed steroid tapering: Prednisolone should be reduced gradually over 8 weeks; rapid reduction leads to early relapse 1

2. Missing infectious causes: Always rule out infectious colitis before confirming IBD diagnosis 3, 4, 5

3. Overlooking complications: Monitor for toxic megacolon, perforation, or severe bleeding which require immediate surgical intervention 1, 6

4. Inadequate monitoring: Regular assessment of disease activity through clinical symptoms, inflammatory markers, and when necessary, endoscopic evaluation is essential

5. Medication side effects: High-dose mesalazine may cause gastrointestinal side effects in some patients 7, 8

By following this structured approach based on disease severity, patients with ileocolitis can achieve symptom control, maintain remission, and minimize complications that affect morbidity, mortality, and quality of life.