What is the recommended management approach for Inflammatory Bowel Disease (IBD) according to Indian consensus?

Indian Consensus on Inflammatory Bowel Disease Management

According to the most recent guidelines, the management of Inflammatory Bowel Disease (IBD) in India should follow a structured approach with early immunomodulation for steroid-dependent disease, and consideration of biologics for refractory cases, with surgery reserved for specific indications when medical management fails. 1

Diagnostic Evaluation

• Endoscopic examination with biopsies is essential for diagnosis and disease assessment
• Initial workup should include:
  • Stool studies (bacterial pathogens, C. difficile toxin, parasites)
  • Inflammatory markers (fecal lactoferrin, calprotectin)
  • Blood tests (CBC, CMP, CRP, ESR, TSH)
• Early colonoscopy or flexible sigmoidoscopy with biopsy within 2 weeks of symptom onset 1

Medical Management Approach

For Ulcerative Colitis (UC)

1. Mild to Moderate Disease:

   • First-line: Mesalazine oral (≥2.4 g/day) combined with mesalazine enemas (1 g/day) for distal disease 1
   • Monitor response within 2-4 weeks

2. Moderate to Severe Disease:

   • Systemic corticosteroids for patients not responding to mesalazine 1
   • IV corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) for acute severe disease 1

3. Steroid-Dependent or Refractory Disease:

   • Immunomodulators: Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) 1
   • Consider biologics (infliximab) if no response to immunomodulators 1

For Crohn's Disease (CD)

1. Mild to Moderate Disease:

   • Avoid overprescription of mesalamine as it has limited efficacy in CD 2
   • Consider early introduction of immunomodulators for better outcomes 3

2. Moderate to Severe Disease:

   • Immunomodulators: Azathioprine, mercaptopurine, or methotrexate 4
   • Biologics for refractory cases

3. Perianal or Fistulizing Disease:

   • Antibiotics: Metronidazole 400 mg TID and/or ciprofloxacin 500 mg BID 1
   • Immunomodulators: Azathioprine or mercaptopurine 1
   • Infliximab for refractory cases 1

Surgical Management Indications

Emergency Surgery Required For:

• Toxic megacolon with perforation
• Massive bleeding with hemodynamic instability
• Clinical deterioration and signs of shock
• Free perforation and generalized peritonitis 4

Surgery Should Be Considered When:

• No clinical improvement after 24-48 hours of medical treatment for toxic megacolon 4
• Symptomatic intestinal strictures not responding to medical therapy and not amenable to endoscopic dilation 4
• Disease not responding to intensive medical therapy 4

Surgical Approach:

• Open approach recommended for hemodynamically unstable patients with free perforation or toxic megacolon 4
• Laparoscopic approach may be considered for stable patients to reduce length of stay and morbidity 4
• For UC requiring emergency surgery, subtotal colectomy with ileostomy is the procedure of choice 4
• For CD, resections should be limited to macroscopic disease 4

Maintenance Therapy and Follow-up

• Lifelong maintenance therapy recommended for UC patients, especially those with left-sided or extensive disease 1
• Options include aminosalicylates, azathioprine/mercaptopurine, or methotrexate 1
• Regular monitoring of disease activity through clinical assessment and laboratory tests
• Surveillance colonoscopy for colorectal cancer risk:
  • Initial colonoscopy after 8-10 years to re-evaluate disease extent
  • For extensive colitis: every 3 years in second decade, every 2 years in third decade, and annually in fourth decade of disease 4
  • Four random biopsies every 10 cm from the entire colon plus samples from suspicious areas 4

Special Considerations

• Nutritional Support: Mandatory in severely undernourished patients 4
• Thromboembolism Prophylaxis: LMWH recommended due to high risk in IBD patients 4
• Medication Timing: Weaning off steroids (ideally 4 weeks before surgery) and stopping immunomodulators with anti-TNF agents to decrease postoperative complications 4

Common Pitfalls to Avoid

• Delaying corticosteroid treatment in acute UC while waiting for stool results 1
• Inappropriate use of steroids for perianal CD or when sepsis is present 2
• Delayed introduction or underdosing of immunomodulators 2
• Failure to consider timely surgery when indicated 2
• Neglecting maintenance therapy in UC patients 1
• Overlooking thromboembolism risk in severe UC patients 1

The management of IBD has evolved from traditional step-up therapy to more aggressive approaches with earlier introduction of immunomodulators and biologics in selected patients with poor prognostic factors 3, 5. This time-structured approach is essential to prevent disease progression and complications while improving quality of life for patients with IBD.