What is the management for an adult patient with moderate to severe Inflammatory Bowel Disease (IBD), including both Crohn's Disease (CD) and Ulcerative Colitis (UC)?

Management of Inflammatory Bowel Disease

For moderate to severe IBD, initiate immunomodulators (azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.25 mg/kg/day) as first-line steroid-sparing agents, escalating to anti-TNF therapy (infliximab 5 mg/kg) only after failure of conventional therapy, with surgery reserved for medical refractory disease or complications. 1

Disease-Specific Initial Treatment

Ulcerative Colitis

• Mild to moderate disease: Start topical mesalazine combined with oral mesalamine 4g/day as first-line therapy 2, 3
• Add topical corticosteroids if inadequate response within 2-4 weeks 2, 3
• Moderate to severe disease: Prednisolone 40mg daily, tapering by 5mg weekly over 8 weeks, combined with oral 5-ASA 3
• If no response within 2 weeks of corticosteroids, initiate advanced therapy 3
• High-dose mesalamine (4g/day) achieves endoscopic remission rates comparable to anti-TNF therapy and should be continued long-term for maintenance 3

Crohn's Disease

• Ileocecal disease (mild-moderate): Budesonide 9mg once daily for 8 weeks—equally effective as prednisolone with significantly fewer side effects 2, 3, 4
• Colonic disease (mild-moderate): Prednisolone 40mg tapering by 5mg weekly, or consider exclusive enteral nutrition for motivated patients avoiding corticosteroids 2, 3
• Severe disease: Intravenous hydrocortisone 400mg/day or methylprednisolone 60mg/day, with concomitant IV metronidazole when septic complications cannot be excluded 4

Steroid-Dependent and Refractory Disease

Immunomodulator Therapy

• Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.25 mg/kg/day are first-line agents for steroid-dependent disease (defined as relapse when steroid dose reduced below 20mg/day or within 6 weeks of stopping) 1
• Check FBC within 4 weeks of starting therapy and every 6-12 weeks thereafter to detect neutropenia, though profound neutropenia can develop rapidly despite monitoring 1
• Methotrexate IM 25mg weekly for 16 weeks, then 15mg weekly, is effective for chronic active Crohn's disease; oral dosing works for many patients 1, 2

Biologic Therapy

• Infliximab 5 mg/kg should be reserved for patients with moderate to severe disease who are refractory to or intolerant of steroids, mesalazine, azathioprine/mercaptopurine, and methotrexate, and where surgery is inappropriate 1
• For ulcerative colitis patients with inadequate response or intolerance to one or more TNF blockers, tofacitinib 10mg twice daily for induction achieves 18% remission at 8 weeks (versus 8% placebo), though only 11% remission in prior TNF-failure patients 5

Long-Term Maintenance Strategy

• Never use corticosteroids for maintenance therapy—lifelong maintenance requires aminosalicylates, azathioprine, or mercaptopurine 2, 3
• Continue high-dose mesalamine (4g/day) indefinitely in responders, particularly with left-sided or extensive disease, as it reduces colorectal cancer risk 2
• Perform initial surveillance colonoscopy at 8-10 years after symptom onset to re-evaluate disease extent 2

Surgical Indications and Principles

Ulcerative Colitis

• Surgery is indicated for disease not responding to intensive medical therapy, dysplasia/carcinoma, poorly controlled disease, or recurrent acute-on-chronic episodes 1
• Subtotal colectomy leaving a long rectal stump (incorporated into lower abdominal wound or exteriorized as mucus fistula) is the procedure of choice in acute fulminant disease 1
• Counsel elective surgery patients regarding all options, including ileo-anal pouch where appropriate 1

Crohn's Disease

• Surgery should only be undertaken for symptomatic (not asymptomatic radiologic) disease, as it is potentially panenteric and usually recurs 1
• Resections must be limited to macroscopic disease only 1, 3
• Never perform primary anastomosis in the presence of sepsis and malnutrition 1

General Surgical Principles

• Patients requiring surgery are best managed under joint care of a gastroenterologist and colorectal surgeon with IBD expertise 1, 2, 3
• Preoperative stoma site marking should be performed by a clinical colorectal nurse specialist 1
• Use midline incisions for IBD patients requiring laparotomy 1

Monitoring and Objective Endpoints

• Never rely on symptoms alone—always use objective inflammatory markers (fecal calprotectin, CRP, endoscopy) to guide treatment decisions 2
• Treat to target: confirm remission using objective endpoints including biochemical, endoscopic, and histologic remission 3
• Tight control: adjust therapy using surrogate biomarkers to maintain control of inflammation 6

Pain Management

• Abdominal pain has multiple mechanisms: acute/subacute obstruction, serosal/mucosal inflammation, visceral hypersensitivity, secondary IBS, or visceral distension 1
• Consider gallstones, renal calculi, and chronic pancreatitis as alternative causes 1
• Treat the underlying cause (including corticosteroids and treatment of associated IBS) rather than relying on analgesics 1
• When non-specific pain relief is needed, tramadol has less effect on motility than other opioids 1

Critical Pitfalls to Avoid

• Do not stop immunosuppressive medications without consulting the IBD team—this precipitates disease flares 2
• Ensure VTE prophylaxis with subcutaneous heparin during hospitalizations, as active IBD significantly increases thrombotic risk 2
• Do not combine biologic DMARDs with other biologics or potent immunosuppressants (azathioprine, cyclosporine) 5
• Avoid overprescription of mesalamine for Crohn's disease and inappropriate steroid use for perianal disease, sepsis, or maintenance 7