What is the recommended management and treatment approach for a patient presenting with symptoms suggestive of inflammatory bowel disease?

Management of Inflammatory Bowel Disease

The initial management of suspected IBD requires a stepwise diagnostic approach using fecal calprotectin measurement, followed by endoscopy with biopsy and cross-sectional imaging to confirm diagnosis and rule out ongoing inflammation, with treatment selection based on disease type, severity, and location. 1, 2

Diagnostic Algorithm

Primary Care Assessment

For patients aged 16-40 with new lower GI symptoms lasting >4 weeks:

• Measure fecal calprotectin (not appropriate if NSAID use in past 6 weeks) 1

  • <100 μg/g: IBS likely, treat as IBS in primary care 1
  • 100-250 μg/g: Consider repeat testing or routine gastroenterology referral 1
  • >250 μg/g: Urgent gastroenterology referral 1

• Immediate referral via suspected cancer pathway if: rectal bleeding PLUS any of abdominal pain, change in bowel habit, weight loss, iron deficiency anemia, OR abdominal/rectal/anal mass, OR unexplained anal ulceration 1

• Obtain baseline labs: full blood count, urea & electrolytes, CRP, coeliac screen, +/- stool culture 1

Specialist Evaluation

Perform full colonoscopy with ileoscopy and systematic biopsies from each segment to establish diagnosis, distinguish Crohn's disease from ulcerative colitis, and assess disease extent and severity 3, 1

• Fecal calprotectin is a validated biomarker for endoscopic and histological disease activity 1
• Serial calprotectin monitoring may facilitate anticipatory management in patients with indeterminate levels and mild symptoms 1

Treatment Approach by Disease Type

Mild to Moderate Ulcerative Colitis

First-line: Aminosalicylates (5-ASA compounds) for inducing and maintaining remission 2

• 5-ASA compounds are effective for both induction and maintenance in UC 2
• Less effective in Crohn's disease 2

Moderate to Severe Crohn's Disease or Ulcerative Colitis

For patients with inadequate response to conventional therapy:

• Infliximab (RENFLEXIS) 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks for maintenance 4
  • Indicated for reducing signs/symptoms and inducing/maintaining clinical remission 4
  • For fistulizing Crohn's disease: reduces draining enterocutaneous and rectovaginal fistulas 4
  • Critical warning: Screen for latent tuberculosis and initiate treatment before starting therapy 4
  • Monitor for: serious infections (bacterial, viral, fungal including histoplasmosis), malignancy risk (especially hepatosplenic T-cell lymphoma in young males on concomitant azathioprine/6-mercaptopurine) 4

Chronic Active Steroid-Dependent Disease

Immunomodulators (azathioprine, mercaptopurine) are recommended 2

• Require regular monitoring of full blood count to detect neutropenia 2
• Avoid concomitant use with TNF-blockers in young males due to increased risk of hepatosplenic T-cell lymphoma 4

Management of Persistent Symptoms in Established IBD

Rule Out Active Inflammation First

Follow stepwise approach: 1

1. Measure fecal calprotectin 1
2. Perform endoscopy with biopsy 1
3. Obtain cross-sectional imaging 1

Evaluate Alternative Causes

Consider anatomic abnormalities if obstructive symptoms present (abdominal distention, pain, nausea, vomiting, constipation) 1, 2

Evaluate alternative mechanisms based on symptom patterns: 1, 2

• Small intestinal bacterial overgrowth 1, 2
• Bile acid diarrhea 1, 2
• Carbohydrate intolerance 1, 2
• Chronic pancreatitis 1

Symptom-Specific Management in Quiescent IBD

Chronic Diarrhea

Use hypomotility agents or bile-acid sequestrants 1, 2, 5

Chronic Constipation

Offer osmotic and stimulant laxatives 1, 2, 5

Functional Pain

Use antispasmodics (hyoscine butylbromide, dicycloverine, peppermint oil), neuropathic-directed agents, or antidepressants 1, 2, 5

• Avoid opiates due to risk of dependence, sedation, and worsening GI dysmotility 1, 5

Defecatory Disorders

Offer pelvic floor therapy 1

Adjunctive Therapies for Functional Symptoms

Dietary Interventions

Low FODMAP diet may be offered with careful attention to nutritional adequacy 1, 2, 5

Psychological Therapies

Consider cognitive behavioral therapy, hypnotherapy, or mindfulness therapy 1, 2, 5

Other Interventions

• Probiotics may be considered 1, 2, 5
• Encourage physical exercise 1, 2, 5

Not Recommended

• Do not offer fecal microbiota transplant for functional GI symptoms until further evidence available 1
• Do not routinely offer complementary and alternative therapies until further evidence available 1

Surgical Considerations

For ulcerative colitis not responding to intensive medical therapy: surgery is recommended, with decisions made jointly by gastroenterologist and colorectal surgeon in consultation with patient 2

For Crohn's disease: surgery should only be considered when symptomatic, as disease is potentially panenteric and usually recurs following surgery 2

Critical Pitfalls to Avoid

• Do not escalate immunosuppression without first ruling out active inflammation through objective measures (calprotectin, endoscopy, imaging), as overtreatment for functional symptoms increases adverse effects without benefit 1
• Screen for tuberculosis before initiating biologic therapy to prevent reactivation 4
• Avoid azathioprine/6-mercaptopurine with TNF-blockers in adolescent/young adult males due to hepatosplenic T-cell lymphoma risk 4
• Patients who do not respond to infliximab by week 14 are unlikely to respond with continued dosing and should have therapy discontinued 4