What is the management approach for inflammatory bowel disease?

Management of Inflammatory Bowel Disease

Inflammatory bowel disease requires a structured, time-based treatment approach that prioritizes disease classification (Crohn's disease versus ulcerative colitis), disease extent and severity, and rapid escalation when initial therapy fails to achieve remission within defined timeframes.

Initial Disease Classification and Assessment

Before initiating therapy, classify the disease type and severity:

• For Crohn's Disease: Assess anatomic location (ileal, ileocolic, colonic), disease pattern (inflammatory, stricturing, fistulating), and activity level 1
• For Ulcerative Colitis: Determine disease extent (distal versus extensive) and severity using clinical parameters including stool frequency, blood in stool, pulse rate, and inflammatory markers 2, 1
• Exclude infectious causes through stool testing before diagnosing IBD, though corticosteroid therapy should not be delayed while awaiting stool microbiology results in severe presentations 2, 3

Ulcerative Colitis Management Algorithm

Mild to Moderate Distal UC

Combination therapy is superior to monotherapy and should be used first-line:

• Topical mesalazine 1g daily PLUS oral mesalazine 2.4-4g daily provides prompt symptom relief and is more effective than either agent alone 2, 1, 3
• Topical corticosteroids can substitute for topical mesalazine if mesalazine is not tolerated 2
• Proximal constipation should be treated with stool bulking agents or laxatives 2

Mild to Moderate Extensive UC

• Oral mesalazine 2-4g daily or balsalazide 6.75g daily as first-line therapy 1
• If inadequate response after 2-4 weeks, add oral prednisolone 40mg daily with gradual taper over 8 weeks 2, 4

Severe UC (Meeting Truelove and Witts' Criteria)

Immediate hospitalization with joint gastroenterology-surgical management is mandatory:

• Intravenous hydrocortisone 400mg/day or methylprednisolone 60mg/day 3
• Intravenous fluid and electrolyte replacement to correct dehydration 2, 3
• Subcutaneous low-molecular-weight heparin for thromboprophylaxis 2, 3
• Blood transfusion to maintain hemoglobin >10 g/dL 2
• Daily monitoring: vital signs four times daily, stool chart, complete blood count, inflammatory markers (ESR or CRP), electrolytes, albumin, liver function tests 2, 3
• Daily abdominal radiography if colonic dilatation (transverse colon >5.5cm) detected 2, 3
• Nutritional support if malnourished 2

Critical timeframe: If no improvement within 7-10 days of intravenous corticosteroids, escalate to rescue therapy (infliximab or cyclosporine) or proceed to colectomy 3. Patients should be informed of a 25-30% chance of requiring colectomy 2, 4.

UC Maintenance Therapy

• Lifelong maintenance therapy is recommended for all patients with left-sided or extensive disease, and those with distal disease relapsing more than once yearly 2, 1
• Aminosalicylates, azathioprine 1.5-2.5mg/kg/day, or mercaptopurine 0.75-1.5mg/kg/day 1, 3
• Maintenance therapy reduces colorectal cancer risk 2

Crohn's Disease Management Algorithm

Mild CD

• High-dose mesalazine 4g daily as initial therapy 1
• Note: Mesalazine is overprescribed for CD and has limited benefit compared to UC 5

Moderate to Severe CD

• Oral prednisolone 40mg daily with gradual reduction over 8 weeks according to clinical response 2, 1, 4
• More rapid steroid reduction is associated with early relapse 4
• Starting dose of 5mg/kg for infliximab at weeks 0,2, and 6, then every 8 weeks for patients with inadequate response to conventional therapy 1, 6
• Some patients may benefit from increasing infliximab dose to 10mg/kg if they lose response 6

Chronic Active or Steroid-Dependent CD

Steroid-sparing immunomodulators are essential:

• Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day as first-line immunomodulators 1, 4
• These agents are often introduced too late or underdosed in clinical practice 5

Fistulizing CD

• Infliximab 5mg/kg at weeks 0,2, and 6, then every 8 weeks for reducing draining enterocutaneous and rectovaginal fistulas 6

CD Maintenance Therapy

• Smoking cessation is crucial 1
• Mesalazine has limited benefit for CD maintenance 1
• Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day are effective second-line options 1

Biologic Therapy Considerations

Infliximab (and other anti-TNF agents) should be used strategically:

• Screen for latent tuberculosis before initiating; if positive, start TB treatment prior to infliximab 6
• Monitor all patients for active TB during treatment, even if initial test negative 6
• Contraindicated in moderate to severe heart failure (doses >5mg/kg) 6
• Discontinue if serious infection develops 6
• Increased risk of lymphoma and other malignancies, particularly hepatosplenic T-cell lymphoma in young males with CD or UC receiving concomitant azathioprine or 6-mercaptopurine 6

Common Pitfalls to Avoid

• Never delay corticosteroids while awaiting stool cultures in suspected severe UC 3
• Never use anti-diarrheal medications in severe colitis 3
• Never continue IV corticosteroids beyond 7-10 days without escalating to rescue therapy or surgery 3
• Never use steroids inappropriately for perianal CD, when sepsis is present, or for maintenance therapy 5
• Never use anti-TNF therapy when sepsis or fibrostenotic strictures are present 5
• Avoid overprescribing mesalazine for CD where it has limited efficacy 5

Surgical Indications

UC Surgery

• Disease not responding to intensive medical therapy after 7-10 days 1, 3
• Dysplasia or carcinoma 1
• Hemodynamic instability, free perforation, toxic megacolon, or massive hemorrhage 3
• Subtotal colectomy with ileostomy is the procedure of choice for severe/fulminant disease 3

CD Surgery

• Limited to symptomatic disease with conservative resections of macroscopic disease only 1
• Surgery for complications or refractory disease 7