What is the management approach for colorectal conditions?

Management Approach for Colorectal Conditions

The management of colorectal conditions requires a disease-specific approach based on whether the patient has inflammatory bowel disease (IBD) or colorectal cancer (CRC), with treatment strategies tailored to disease type, location, severity, and pattern.

Inflammatory Bowel Disease Management

Ulcerative Colitis (UC)

Mild to Moderate Distal UC:

• First-line therapy: Combination of topical mesalazine 1g daily plus oral mesalazine 2-4g daily 1
• Topical corticosteroids should be reserved as second-line therapy for patients intolerant to topical mesalazine 1
• For non-responders to combination therapy, use oral prednisolone 40mg daily with gradual tapering over 8 weeks 1

Severe UC:

• Requires hospitalization for intensive intravenous therapy 1
• Joint management by gastroenterologist and colorectal surgeon is essential 1
• Daily monitoring protocol:
  • Physical examination for abdominal tenderness
  • Vital signs four times daily
  • Stool chart documentation
  • Laboratory tests every 24-48 hours (FBC, ESR/CRP, electrolytes, albumin, liver function)
  • Abdominal radiography if colonic dilatation present
• Treatment includes:
  • IV fluid and electrolyte replacement
  • Subcutaneous heparin for thromboembolism prevention
  • Nutritional support if malnourished 1
• Patients should be informed about 25-30% chance of needing colectomy 1

Maintenance Therapy for UC:

• Lifelong maintenance therapy with aminosalicylates, azathioprine, or mercaptopurine 1
• Especially important for patients with left-sided/extensive disease or those with distal disease who relapse more than once yearly 1

Crohn's Disease (CD)

Active Ileal/Ileocolonic/Colonic Disease:

• Mild disease: High-dose mesalazine (4g daily) 1
• Moderate to severe disease: Oral corticosteroids (prednisolone 40mg daily) with gradual tapering over 8 weeks 1
• Isolated ileo-cecal disease: Budesonide 9mg daily 1
• For steroid-dependent patients: Immunomodulation with azathioprine, mercaptopurine, or methotrexate 1

Colorectal Cancer Management

Surgical Approach:

• Surgery is the cornerstone of treatment for localized disease 1
• For UC patients requiring surgery: Joint decision between gastroenterologist and colorectal surgeon 1
• For CD patients: Surgery only for symptomatic disease, with conservative resections 1
• Preoperative stoma site marking by a clinical colorectal nurse specialist 1

Chemotherapy for Advanced Disease:

• Standard regimen: Oxaliplatin 85mg/m² IV over 120 minutes plus leucovorin 200mg/m² IV over 120 minutes, followed by fluorouracil bolus and continuous infusion 2
• For adjuvant treatment: Continue for up to 12 cycles or until unacceptable toxicity 2
• For advanced colorectal cancer: Continue until disease progression or unacceptable toxicity 2
• Dose modifications based on adverse reactions, particularly for peripheral sensory neuropathy, myelosuppression, and gastrointestinal toxicity 2

Follow-up After Treatment:

• Clinical visits every 3 months for first 3 years, then every 6 months for 2 more years 1
• Complete colonoscopy at initial diagnosis, then every 5 years if no findings 1
• For high-risk disease: CT scan of chest and abdomen every 6-12 months 1
• CEA testing for patients amenable to resection of recurrence 1
• For patients with local excision of rectal cancer: Digital rectal examination and sigmoidoscopy every 3-6 months for 3 years 1

Malignant Polyp Management:

• Multidisciplinary approach involving gastroenterologist, pathologist, oncologist, and surgeon 1
• Decision for surgical resection based on:
  • Patient factors: Age, comorbidity, preferences
  • Polyp features: Size, histology, unfavorable features
  • Risk assessment of residual/metastatic disease versus surgical risk 1

Pain Management in Colorectal Conditions

• Identify underlying cause (obstruction, inflammation, visceral hypersensitivity)
• Treat underlying cause when possible (corticosteroids for inflammation)
• For non-specific pain relief: Consider opioids with less effect on motility, such as tramadol 1

Colorectal Cancer Screening and Prevention

• Regular screening is crucial as CRC can be asymptomatic for 7-10 years 3
• Screening methods include colonoscopy, fecal immunochemical tests, and flexible sigmoidoscopy 4
• Countries with early and high uptake of effective screening show major declines in CRC incidence and mortality 5

Common Pitfalls and Caveats

1. Delaying corticosteroid treatment in acute UC while waiting for stool microbiology results 1
2. Failing to consider joint medical and surgical management for severe UC 1
3. Overlooking thromboembolism risk in severe UC patients 1
4. Performing primary anastomosis in the presence of sepsis and malnutrition 1
5. Neglecting maintenance therapy in UC patients, which may increase colorectal cancer risk 1
6. Overtreatment with surgery for asymptomatic, radiologically identified CD 1
7. Inadequate follow-up after colorectal cancer treatment 1