What is the comprehensive management plan for a patient with inflammatory bowel disease?

Comprehensive Management of Inflammatory Bowel Disease

The management of IBD requires a structured approach prioritizing disease location, severity, and phenotype, with combination topical and oral mesalazine as first-line for ulcerative colitis and corticosteroids or high-dose mesalazine for Crohn's disease, escalating to immunomodulators and biologics for refractory or severe disease, while maintaining lifelong therapy to prevent relapse and reduce cancer risk. 1

Initial Assessment and Disease Classification

Ulcerative Colitis

• Determine disease extent and severity immediately through colonoscopy with biopsy, which is the diagnostic test of choice 2
• Classify as mild-moderate distal/left-sided disease versus severe/extensive disease to guide treatment intensity 1, 3
• For severe UC, admit immediately for IV corticosteroids—do not delay for stool cultures 1

Crohn's Disease

• Identify disease location (ileal, ileocolonic, colonic, perianal) and behavior (inflammatory, stricturing, fistulating) through ileocolonoscopy 2
• Consider esophagogastroduodenoscopy if upper GI involvement suspected 2
• MRI and examination under anesthesia are essential for defining perianal disease anatomy 1

Treatment Strategy by Disease Type and Severity

Ulcerative Colitis: Mild to Moderate Distal Disease

Start combination therapy immediately—this is superior to monotherapy:

• Topical mesalazine 1g daily PLUS oral mesalazine 2-4g daily 1, 3
• This combination is more effective than either agent alone for controlling inflammation 3
• Once-daily dosing improves adherence without compromising efficacy 3

If mesalazine fails or intolerant:

• Topical corticosteroids as second-line 1
• Oral prednisolone 40mg daily when prompt response needed, tapered gradually over 8 weeks 1
• Budesonide MMX 9mg/day for left-sided disease as alternative to conventional steroids 3

Ulcerative Colitis: Severe Disease

This is a medical emergency requiring immediate hospitalization:

• Joint management by gastroenterologist AND colorectal surgeon from admission 1
• IV corticosteroids, fluid/electrolyte replacement, transfuse to maintain hemoglobin >10g/dL 1
• Monitor vital signs four times daily, daily stool charts, labs (FBC, CRP, electrolytes, albumin) every 24-48 hours 1
• Daily abdominal radiographs if colonic dilatation >5.5cm detected 1
• Subcutaneous heparin for thromboembolism prophylaxis 1
• Assess response by day 3; consider rescue therapy with infliximab or ciclosporin for non-responders 1
• Inform patients of 25-30% colectomy risk 1, 3

Crohn's Disease: Active Mild to Moderate Ileocolonic Disease

Choose initial therapy based on disease characteristics:

• High-dose mesalazine 4g daily may suffice as first-line 1
• Corticosteroids for moderate-severe disease requiring prompt remission 1
• Budesonide for ileal/right-sided colonic disease—lower systemic effects than prednisolone 1
• Nutritional therapy or antibiotics based on patient preference 1

Critical caveat: Mesalazine has limited benefit and is ineffective at doses <2g/day or for patients who needed steroids to induce remission 4

Crohn's Disease: Steroid-Dependent or Refractory Disease

Escalate to immunomodulators as second-line:

• Azathioprine 1.5-2.5mg/kg/day OR mercaptopurine 0.75-1.5mg/kg/day 4, 1
• Slow onset of action precludes use as sole therapy—use as adjunctive and steroid-sparing agent 4

For azathioprine intolerance or failure:

• Methotrexate 25mg IM weekly for 16 weeks, then 15mg weekly for maintenance 1
• Add folic acid 5mg weekly (3 days after methotrexate) to reduce side effects 4, 1
• Subcutaneous or oral methotrexate may be effective alternatives 4

For moderate-severe disease refractory to conventional therapy:

• Infliximab 5mg/kg at weeks 0,2, and 6 1, 5
• Reserved for patients refractory to steroids, mesalazine, and immunomodulators where surgery inappropriate 1
• Maintenance dosing: 5-10mg/kg every 8 weeks for responders 4, 1
• Use as part of comprehensive strategy including immunomodulation and surgical consultation 1
• Avoid in patients with obstructive symptoms 4

Perianal and Fistulating Crohn's Disease

Structured approach combining medical and surgical therapy:

First-line antibiotics for simple perianal fistulae:

• Metronidazole 400mg TDS and/or ciprofloxacin 500mg BD 4, 1

After excluding distal obstruction and abscess:

• Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day 4, 1

For refractory fistulae:

• Infliximab (three infusions of 5mg/kg at 0,2,6 weeks) combined with immunomodulation and surgical drainage 4, 1, 5
• Seton drainage, fistulectomy, or advancement flaps for persistent/complex fistulae 4, 1
• Elemental diets or parenteral nutrition as adjunctive therapy only, not sole therapy 4

Maintenance Therapy to Prevent Relapse

Ulcerative Colitis

Lifelong maintenance is mandatory:

• Mesalazine ≥2g daily for all patients, especially those with left-sided or extensive disease 1, 3
• Maintenance therapy reduces colorectal cancer risk 1

For steroid-dependent patients:

• Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day 1

Crohn's Disease

Smoking cessation is the single most important factor:

• All smokers must stop—offer counseling, nicotine patches, or substitutes 4, 1

Pharmacologic maintenance:

• Mesalazine has limited benefit, ineffective at <2g/day or after steroid-induced remission 4, 1
• Azathioprine/mercaptopurine effective but reserved as second-line due to toxicity 4, 1
• Methotrexate 15-25mg IM weekly for patients who responded to IM methotrexate induction 4, 1
• Infliximab 5-10mg/kg every 8 weeks for responders, effective up to 44 weeks 4

Critical warning: Corticosteroids including budesonide are NOT effective for maintenance and cause steroid dependency—never use long-term 4, 1

Surgical Management

Ulcerative Colitis

Indications for surgery:

• Disease not responding to intensive medical therapy 1
• Dysplasia or carcinoma 1

Surgical approach:

• Subtotal colectomy with long rectal stump for acute fulminant disease 1
• Counsel regarding ileo-anal pouch for elective surgery 1

Crohn's Disease

Conservative surgical principles:

• Operate only for symptomatic disease, not asymptomatic radiologic findings 1
• Resections limited to macroscopic disease only—be conservative 1
• Avoid primary anastomosis in presence of sepsis and malnutrition 1
• Consider stricture dilatation or strictureplasty for diffuse small bowel disease 4, 1
• Nutritional support before and after surgery is essential 4, 1

Monitoring and Treatment Targets

Shift from symptom-based to objective measures:

• Target endoscopic healing, not just clinical remission—symptoms do not correlate with inflammation 6, 7
• Monitor non-invasive biomarkers: C-reactive protein and fecal calprotectin 6
• Tight monitoring with drug concentration measurement improves outcomes 6
• Always exclude infectious causes before attributing symptoms to IBD flare 3

Special Populations and Sites

Gastroduodenal Crohn's Disease

• Symptoms often relieved by proton pump inhibitors 4
• Surgery difficult and may be complicated by fistulation 4

Oral Crohn's Disease

• Manage with specialist in oral medicine 4
• Topical steroids, topical tacrolimus, intra-lesional steroid injections, enteral nutrition, or infliximab may have role 4

Critical Safety Warnings for Infliximab

Boxed warnings from FDA:

• Increased risk of serious infections leading to hospitalization or death, including TB, bacterial sepsis, invasive fungal infections 5
• Perform test for latent TB; if positive, start TB treatment prior to starting infliximab 5
• Monitor all patients for active TB during treatment, even if initial latent TB test negative 5
• Lymphoma and other malignancies, some fatal, reported in children and adolescents 5
• Fatal hepatosplenic T-cell lymphoma (HSTCL) reported, especially in adolescent/young adult males with CD/UC receiving azathioprine or 6-mercaptopurine concomitantly 5
• Carefully assess risk/benefit, especially if patient has CD/UC, is male, and receiving azathioprine or 6-mercaptopurine 5