What is the first line management for a patient with chronic diarrhea and transmural inflammation on colonoscopy?

First-Line Management for Crohn's Disease with Transmural Inflammation

The answer is C. Prednisolone - oral corticosteroids such as prednisolone 40 mg daily represent the appropriate first-line therapy for moderate to severe Crohn's disease presenting with transmural inflammation on colonoscopy. 1

Clinical Context

Transmural inflammation on colonoscopy is pathognomonic for Crohn's disease (CD), distinguishing it from ulcerative colitis which demonstrates only mucosal inflammation. 1 This finding indicates the patient has active inflammatory CD requiring prompt medical management. 1

Treatment Algorithm Based on Disease Severity

For Mild Ileocolonic Disease:

• High-dose mesalazine (4 g/daily) may be sufficient as initial therapy 1, 2
• However, this has limited efficacy compared to corticosteroids 1

For Moderate to Severe Disease (Most Likely Scenario):

Prednisolone 40 mg daily orally is the appropriate first-line treatment 1, 2

• Should be reduced gradually over 8 weeks according to severity and patient response 1
• More rapid reduction is associated with early relapse 1

Why Not the Other Options:

Methotrexate (Option A):

• Reserved for maintenance therapy in patients whose active disease has already responded to methotrexate 1
• Appropriate for those intolerant of or who have failed azathioprine/mercaptopurine 1
• Not a first-line induction agent - used as second-line therapy 1

Infliximab (Option B):

• Effective for moderate to severe CD (Grade A evidence) 1, 2
• However, reserved for patients refractory to or intolerant of steroids, mesalazine, and immunomodulators 1
• Should be used as part of a treatment strategy including immunomodulation, once other options including surgery have been discussed 1
• Not appropriate as initial first-line therapy 1

Important Clinical Considerations

Severity Assessment:

The guidelines emphasize assessing disease severity before treatment decisions 1. Without additional information suggesting severe disease requiring hospitalization (such as toxic megacolon, severe systemic symptoms), moderate disease is most likely, making oral prednisolone the optimal choice. 1

Steroid Tapering Protocol:

• Prednisolone should be reduced gradually over 8 weeks 1
• Rapid reduction increases risk of early relapse 1
• Monitor for steroid dependence (relapse when dose reduced below 20 mg/day or within 6 weeks of stopping) 1

Common Pitfall to Avoid:

Do not jump directly to biologics like infliximab without first attempting corticosteroid therapy, unless there are specific contraindications to steroids or the patient has already failed conventional therapy. 1 The step-up approach remains standard, with biologics reserved for refractory cases. 1

Adjunctive Considerations:

• If the patient smokes, strongly advise cessation as this is the most important factor in maintaining remission 1
• Consider nutritional assessment and support 1
• Azathioprine may be added as steroid-sparing agent, though its slow onset precludes use as sole therapy 1