What is the management approach for Inflammatory Bowel Disease (IBD) in a patient?

Management of Inflammatory Bowel Disease

IBD management requires a multidisciplinary, structured approach centered on rapid access to care, appropriate medical therapy escalation based on disease severity, and integration of surgical consultation when needed, with the ultimate goal of achieving clinical and endoscopic remission while preventing disease progression and disability. 1, 2

Core Organizational Structure

Establish a multidisciplinary team that includes gastroenterologists, colorectal surgeons, dieticians, and access to psychological support for optimal IBD care. 3

Essential Access Requirements

• Rapid access to clinic appointments for new symptoms and disease relapses 3
• Direct telephone access to the care team for urgent concerns 3
• Continuity of care with the same clinician whenever possible, as patients strongly value this 3
• Private, clean toilet facilities readily available 3

Patient-Centered Care Principles

• Provide sufficient information to enable rational personal choice about treatment options 3
• Respect patient expertise about their own condition and needs 3
• Address physical, emotional, and quality of life issues comprehensively 3
• Ensure close integration of medical and surgical management from the outset 3

Medical Management by Disease Type and Severity

Ulcerative Colitis

Mild to Moderate Distal Disease (Proctitis/Proctosigmoiditis)

First-line: Combination therapy with topical mesalazine 1g daily PLUS oral mesalazine 2-4g daily, as this combination is superior to either agent alone. 1, 2

• Second-line: Add topical corticosteroids if mesalazine is not tolerated or insufficient 1, 2
• Escalate to oral prednisolone 40mg daily if combination mesalazine therapy fails, then taper gradually over 8 weeks based on response 2

Moderate to Severe Extensive Disease

Oral prednisolone 40mg daily for induction, tapered over 8 weeks. 2

Severe Ulcerative Colitis

Admit immediately for intravenous corticosteroids—do not delay for stool cultures. 2

Critical management steps:

• Joint management by gastroenterologist AND colorectal surgeon from admission 2
• Monitor vital signs four times daily 2
• Daily stool charts and labs (FBC, CRP, electrolytes, albumin) every 24-48 hours 2
• Daily abdominal radiographs if colonic dilatation >5.5cm detected 2
• IV fluid/electrolyte replacement and transfuse to maintain hemoglobin >10g/dL 2
• Subcutaneous heparin for thromboembolism prophylaxis (high-risk population) 1, 2
• Assess response by day 3: If no improvement, initiate rescue therapy with infliximab or ciclosporin 1, 2
• Inform patients of 25-30% colectomy risk 2

Maintenance Therapy for UC

Lifelong aminosalicylate maintenance with mesalazine ≥2g daily is recommended for all patients, especially those with left-sided or extensive disease. 1, 2

• This reduces colorectal cancer risk 1, 2
• For steroid-dependent patients: Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day 1, 2

Crohn's Disease

Mild Ileocolonic Disease

High-dose mesalazine 4g daily may be sufficient as initial therapy. 1, 2

• Consider nutritional therapy or antibiotics based on disease characteristics 2

Moderate to Severe Disease

Corticosteroids for induction of remission 1, 2

• Budesonide preferred for ileal/right-sided colonic disease due to lower systemic effects 2
• Do NOT use corticosteroids for maintenance—they are ineffective and cause steroid dependency 2

Steroid-Dependent or Refractory Disease

Second-line: Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day 1, 2

Alternative: Methotrexate 25mg IM weekly for 16 weeks, then 15mg weekly for chronic active disease or azathioprine intolerance 1, 2

• Add folic acid 5mg weekly (3 days after methotrexate) to reduce side effects 2

Moderate-Severe Refractory Disease

Infliximab 5mg/kg at weeks 0,2, and 6 reserved for disease refractory to steroids, mesalazine, and immunomodulators where surgery is inappropriate. 1, 2, 4

• Maintenance dosing: 5-10mg/kg every 8 weeks for responders 1, 2
• Use as part of comprehensive strategy including immunomodulation and surgical consultation 2
• FDA-approved for moderately to severely active disease with inadequate response to conventional therapy 4

Perianal/Fistulating Disease

First-line: Metronidazole 400mg TDS and/or ciprofloxacin 500mg BD for simple perianal fistulae 2

Essential workup:

• MRI and examination under anesthesia to define anatomy 2
• Exclude distal obstruction and abscess before starting immunomodulation 2

For simple fistulae: Azathioprine/mercaptopurine after excluding complications 2

For refractory fistulae: Infliximab (three infusions at 0,2,6 weeks) combined with immunomodulation and surgical drainage 2, 4

• Seton drainage, fistulectomy, or advancement flaps for persistent/complex fistulae 2

Maintenance Therapy for CD

All smokers MUST stop—this is the most important factor in maintaining remission. 2

Maintenance options:

• Azathioprine/mercaptopurine effective but reserved as second-line due to toxicity 2
• Methotrexate 15-25mg IM weekly for patients who responded to IM methotrexate induction 2
• Mesalazine has limited benefit, ineffective at <2g/day or after steroid-induced remission 2

Surgical Management

Indications for Surgery

Ulcerative Colitis:

• Disease not responding to intensive medical therapy 2
• Dysplasia or carcinoma 2

Crohn's Disease:

• Operate only for symptomatic disease, not asymptomatic radiologic findings 2
• Complications such as strictures, fistulas, or abscesses that fail medical management 1

Surgical Principles

For UC:

• Subtotal colectomy with long rectal stump is the procedure of choice for acute fulminant disease 1, 2
• Counsel regarding ileo-anal pouch for elective surgery 2

For CD:

• Resections limited to macroscopic disease only—be conservative 1, 2
• Avoid primary anastomosis in presence of sepsis and malnutrition 2
• Consider stricture dilatation or strictureplasty for diffuse small bowel disease 2

Joint care by surgeon and gastroenterologist is essential for all surgical candidates. 1

Critical Safety Considerations

Infliximab-Specific Warnings

Screen for latent tuberculosis before starting infliximab—if positive, treat TB prior to initiating therapy. 4

Monitor all patients for active TB during treatment, even if initial test is negative. 4

Increased risk of serious infections including bacterial sepsis, invasive fungal infections (histoplasmosis), and opportunistic pathogens—discontinue if serious infection develops. 4

Risk of hepatosplenic T-cell lymphoma (HSTCL), particularly in adolescent/young adult males with Crohn's disease or ulcerative colitis receiving azathioprine or 6-mercaptopurine concomitantly. 4

Contraindicated in doses >5mg/kg in moderate to severe heart failure. 4

Thromboembolism Prophylaxis

Administer LMWH for all hospitalized IBD patients due to high thrombotic risk. 1, 2

Long-Term Monitoring

Regular surveillance for:

• Complications and extraintestinal manifestations 1
• Colorectal cancer screening, especially in long-standing ulcerative colitis 1
• Monitoring of patients on immunomodulator therapy 3

Audit outcomes including:

• Proportion of patients on immunomodulator therapy 3
• Outcome of admission for severe colitis 3
• Time lost to work 3
• Mortality 3

Common Pitfalls to Avoid

Do not delay admission for severe UC while waiting for stool cultures—immediate IV corticosteroids are critical. 2

Do not use corticosteroids for maintenance in CD—this leads to steroid dependency without efficacy. 2

Do not operate on asymptomatic radiologic findings in CD—surgery is only for symptomatic disease. 2

Do not start azathioprine/mercaptopurine for perianal fistulae without first excluding distal obstruction and abscess. 2

Do not ignore smoking cessation in CD—it is the single most important modifiable factor. 2