What is the management approach for inflammatory bowel disease (IBD)?

Management of Inflammatory Bowel Disease (IBD)

The management of inflammatory bowel disease requires a structured approach based on disease type (Crohn's disease or ulcerative colitis), location, severity, and pattern, with treatment escalation from aminosalicylates to immunomodulators and biologics for non-responders. 1

Disease Assessment and Classification

• Distinguish between Crohn's disease (CD) and ulcerative colitis (UC)
• Assess disease severity: mild, moderate, or severe based on symptoms and laboratory findings
• Determine disease extent and location through endoscopy
• Exclude infectious causes before initiating treatment:
  • Stool culture
  • C. difficile toxin assay
  • Inflammatory markers (calprotectin, lactoferrin)

Treatment Approach for Ulcerative Colitis

Mild to Moderate Disease

1. First-line therapy: Oral mesalamine 2-4g/day + topical mesalamine for distal disease 1

   • Standard dose: 2-3g/day for mild disease
   • Higher dose: >3g/day for moderate disease
   • Continue for 4-8 weeks for induction of remission

2. Maintenance therapy: Oral mesalamine (minimum 2g/day) 1

   • Lifelong maintenance generally recommended, especially for left-sided or extensive disease 2
   • Maintenance therapy may reduce colorectal cancer risk 2, 3

Moderate to Severe Disease

1. Corticosteroids: Prednisolone 40mg daily with gradual taper over 6-8 weeks 1

   • Monitor for short-term adverse effects: acne, edema, sleep disturbances, mood changes
   • Long-term adverse effects: osteoporosis, adrenal suppression, increased infection risk

2. Steroid-dependent disease: Consider immunomodulators 2

   • Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.25 mg/kg/day)
   • Monitor FBC within 4 weeks of starting therapy and every 6-12 weeks thereafter

3. Refractory disease: Consider biologics 2, 4

   • Infliximab 5 mg/kg at weeks 0,2, and 6, then every 8 weeks
   • Reserved for patients who fail conventional therapy with steroids, mesalamine, and immunomodulators

Severe/Fulminant Disease

1. Hospital admission for intensive intravenous therapy 2

   • Joint management by gastroenterologist and colorectal surgeon
   • Daily monitoring: vital signs, abdominal examination, stool frequency/character
   • Laboratory monitoring: CBC, CRP, electrolytes, albumin, liver function tests

2. Treatment components:

   • IV fluid and electrolyte replacement
   • Blood transfusion to maintain hemoglobin >10 g/dl
   • Subcutaneous heparin for thromboembolism prophylaxis
   • Nutritional support if malnourished

3. Consider surgery if no response to intensive medical therapy 2, 1

   • Subtotal colectomy with ileostomy is the procedure of choice for severe UC

Treatment Approach for Crohn's Disease

Active Inflammatory Disease

1. First-line options:

   • Corticosteroids for rapid symptom control
   • Consider budesonide for ileal/right-sided colonic disease (fewer systemic effects)

2. Maintenance therapy:

   • Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.25 mg/kg/day) 2
   • Methotrexate 25mg weekly (IM) for induction, then 15mg weekly for maintenance 2

3. Refractory disease:

   • Infliximab 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 2, 4
   • Reserved for moderate to severe CD refractory to conventional therapy

Fistulizing Disease

• Metronidazole and/or ciprofloxacin for perianal disease
• Infliximab for complex or refractory fistulas
• Surgical drainage of abscesses when present

Stricturing Disease

• Endoscopic balloon dilation for short, accessible strictures
• Surgical resection for symptomatic strictures not amenable to endoscopic therapy
• Conservative resections limited to macroscopic disease 2

Monitoring and Follow-up

• Assess clinical response within 3-7 days of initiating therapy 1
• Monitor laboratory markers: WBC, CRP, albumin
• Perform endoscopic assessment after 4-8 weeks to confirm mucosal healing
• Monitor renal function before and during mesalamine therapy

Surgical Management

• Surgery should be considered for:

  • Disease not responding to intensive medical therapy
  • Complications (perforation, massive hemorrhage, toxic megacolon)
  • Dysplasia or carcinoma
  • Poorly controlled disease

• Surgical principles:

  • Joint care by surgeon and gastroenterologist 2
  • Preoperative counseling and stoma site marking by specialist nurse
  • Conservative resections in CD limited to macroscopic disease 2
  • Avoid primary anastomosis in presence of sepsis or malnutrition 2

Common Pitfalls to Avoid

1. Inadequate initial assessment and resuscitation
2. Missing infectious causes (especially C. difficile)
3. Overlooking VTE prophylaxis
4. Inappropriate use of antimotility agents in severe colitis
5. Delayed treatment escalation in non-responders
6. Prolonged steroid use without steroid-sparing strategies
7. Overprescription of mesalamine for CD 5
8. Delayed consideration of surgery in appropriate cases

Special Populations

• Pediatric patients: Similar approach to adults with dose adjustments
• Elderly patients: Consider comorbidities and drug interactions
• Pregnant patients: Most IBD medications are safe during pregnancy; active disease poses greater risk than treatment