How are inflammatory bowel disease symptoms managed?

Management of Inflammatory Bowel Disease Symptoms

The first critical step is to determine whether persistent GI symptoms are due to active inflammation or functional overlay, using fecal calprotectin measurement, endoscopy with biopsy, and cross-sectional imaging in a stepwise approach. 1, 2

Diagnostic Algorithm for Persistent Symptoms

Rule out active inflammation first before attributing symptoms to functional causes, as this distinction fundamentally changes management and prevents both overtreatment with immunosuppression and undertreatment of ongoing disease 1:

• Measure fecal calprotectin (cutoff 30 μg/g has 100% sensitivity for active Crohn's disease) 3
• Perform endoscopy with biopsies to assess mucosal inflammation 4
• Obtain cross-sectional imaging (CT or MRI enterography) to evaluate for structural complications including strictures, abscesses, or bowel wall thickening 2, 3
• Check inflammatory markers (CRP superior to ESR in first 24 hours, plus albumin and CBC) 3

For indeterminate calprotectin levels with mild symptoms, use serial monitoring rather than immediate escalation 1

Management Based on Disease Activity

Active Inflammatory Disease

For mild-to-moderate ulcerative colitis, initiate topical mesalamine 1g daily (suppository for rectosigmoid disease) combined with oral mesalamine 2-4g daily as first-line therapy 3:

• Aminosalicylates are effective for inducing and maintaining remission in UC but less effective in Crohn's disease 2
• For steroid-dependent disease, advance to immunomodulators (azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day) with regular CBC monitoring for neutropenia 2, 4

For moderate-to-severe Crohn's disease, consider infliximab 5 mg/kg at weeks 0,2, and 6, then every 8 weeks after excluding abscess and confirming inflammation 3, 5:

• Patients losing response may benefit from dose escalation to 10 mg/kg 2
• Combination therapy with infliximab plus thiopurines is more effective than monotherapy for inducing and maintaining remission 6

Critical pitfall: Do not escalate immunosuppression if C. difficile infection is present, as this worsens outcomes 4

Quiescent Disease with Functional Symptoms

When inflammation is excluded, address symptoms with targeted therapies based on predominant pattern 1, 2:

For Chronic Diarrhea:

• Use hypomotility agents or bile-acid sequestrants (cholestyramine 4g with meals) 1, 2, 4
• Evaluate for bile acid diarrhea with SeHCAT scan or empiric trial of sequestrants 4
• Test for small intestinal bacterial overgrowth with hydrogen breath testing 4
• Screen for carbohydrate intolerance (lactose, fructose) with breath testing 4

For Chronic Constipation:

• Offer osmotic and stimulant laxatives 1, 2
• Provide pelvic floor therapy if defecatory disorder is identified 1, 2

For Functional Abdominal Pain:

• Use antispasmodics, neuropathic-directed agents (gabapentin, pregabalin), or antidepressants 1, 2
• Avoid opiates entirely due to risk of narcotic bowel syndrome and worsening outcomes 1, 2

Alternative Mechanisms to Evaluate

When obstructive symptoms occur (distention, pain, nausea, vomiting, constipation), consider anatomic abnormalities or structural complications requiring imaging 1, 2:

• Strictures may require endoscopic dilation or surgical intervention 2
• Abscesses require drainage and antibiotic coverage for gram-negatives and anaerobes 3

Evaluate for concurrent conditions based on symptom patterns 1:

• Small intestinal bacterial overgrowth (glucose/lactulose breath test) 4
• Bile acid diarrhea (SeHCAT scan or empiric bile acid sequestrant trial) 4
• Carbohydrate intolerance (breath testing for lactose/fructose) 4
• Celiac disease (tissue transglutaminase IgA with total IgA) 4
• Chronic pancreatitis (if steatorrhea present) 1

Non-Pharmacologic Interventions

Dietary modification with low FODMAP diet may be offered with careful nutritional monitoring, as this addresses carbohydrate malabsorption 1, 2, 4

Psychological therapies are essential for functional symptoms and should include cognitive behavioral therapy, hypnotherapy, or mindfulness therapy 1, 2

Physical exercise should be actively encouraged for all IBD patients with functional symptoms 1, 2

Probiotics may be considered for functional symptoms, though evidence is limited 1, 2

Therapies to Avoid

Do not offer fecal microbiota transplant for functional GI symptoms in IBD until further evidence is available 1, 2

Do not routinely offer complementary and alternative therapies for functional symptoms due to insufficient evidence 1, 2

Surgical Considerations

For ulcerative colitis not responding to intensive medical therapy, surgery should be discussed jointly by gastroenterologist and colorectal surgeon with the patient 2

For Crohn's disease, reserve surgery only for symptomatic disease, as it is potentially panenteric and usually recurs post-operatively 2

Monitoring and Reassessment

Reassess patients in 3-5 days for clinical improvement when treating acute symptoms 3

Repeat imaging if symptoms worsen or fail to improve to assess for complications 3

Monitor for fatigue as a distinct symptom that does not necessarily correlate with disease activity and investigate for subclinical inflammation, anemia, iron deficiency, vitamin deficiencies, sleep disturbance, and medication side effects 2