What is the primary goal and recommended management approach for a patient with inflammatory bowel disease?

Management of Inflammatory Bowel Disease

The primary goal of IBD management is to induce and maintain clinical remission while achieving mucosal healing, which improves long-term outcomes and reduces the need for surgery. 1

Core Treatment Objectives

The management approach must prioritize three key outcomes:

• Inducing remission to eliminate active symptoms and inflammation 2, 3
• Achieving mucosal healing as this directly impacts disease course and reduces complications 1
• Maintaining long-term remission to prevent flares, surgery, and malignancy 4

Disease-Specific Management Algorithms

Ulcerative Colitis Treatment Pathway

For distal UC (mild to moderate):

• Start with combination therapy: topical mesalazine 1g daily PLUS oral mesalazine 2-4g daily as first-line treatment 5, 6, 7
• This combination is more effective than either agent alone 5
• If inadequate response after appropriate trial, escalate to oral prednisolone 40mg daily with gradual taper over 8 weeks 5, 6

For extensive UC (mild to moderate):

• Initiate oral mesalazine 2-4g daily or balsalazide 6.75g daily 5, 7
• Add oral prednisolone 40mg daily if mesalazine fails 5

For severe UC:

• Immediate hospital admission with joint gastroenterology-surgery management 5, 7
• Administer intravenous hydrocortisone 400mg/day or methylprednisolone 60mg/day 5, 7
• Monitor vital signs four times daily, daily stool charts, and FBC/CRP every 24-48 hours 5
• Daily abdominal radiography if colonic dilatation (transverse colon >5.5cm) detected 5
• If no response after 7-10 days of intensive medical therapy, proceed to subtotal colectomy with ileostomy 7

Maintenance therapy for UC:

• Lifelong maintenance with aminosalicylates, azathioprine, or mercaptopurine is recommended for all patients with left-sided or extensive disease 5, 6, 7
• This reduces colorectal cancer risk by up to 75% 8

Crohn's Disease Treatment Pathway

For mild CD:

• Start with high-dose mesalazine 4g daily as initial therapy 6, 7

For moderate to severe CD:

• Oral prednisolone 40mg daily with gradual reduction over 8 weeks according to clinical response 5, 6, 7
• For isolated ileocaecal disease, budesonide 9mg daily is an alternative but marginally less effective than prednisolone 5
• Avoid budesonide beyond 12 weeks and limit to mild ileocaecal disease only 8

For steroid-dependent or chronic active CD:

• Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day as first-line immunomodulators 5, 6, 7
• These agents are effective for maintenance but have slow onset (may take 6 weeks), precluding use as sole therapy for active disease 5, 9

For refractory moderate to severe CD:

• Infliximab 5mg/kg at 0,2, and 6 weeks, then every 8 weeks for patients with inadequate response to conventional therapy 10
• Some patients may benefit from dose escalation to 10mg/kg if they lose response 10
• Avoid infliximab in patients with obstructive symptoms 5

For fistulating CD:

• First-line: Metronidazole 400mg three times daily and/or ciprofloxacin 500mg twice daily for simple perianal fistulae 5
• Second-line: Azathioprine 1.5-2.5mg/kg/day or mercaptopurine 0.75-1.5mg/kg/day after excluding distal obstruction and abscess 5
• Refractory cases: Infliximab (three infusions of 5mg/kg at 0,2, and 6 weeks) as part of combined medical-surgical strategy 5

Nutritional Therapy in IBD

Exclusive enteral nutrition (EEN):

• EEN is effective for inducing clinical remission and endoscopic response in Crohn's disease, with stronger evidence in children than adults 5
• Consider as steroid-sparing bridge therapy for CD patients 5
• Use in malnourished patients before elective CD surgery to optimize nutritional status and reduce postoperative complications 5

Crohn's disease exclusion diet:

• A type of partial enteral nutrition that may induce remission in mild to moderate CD of relatively short duration 5

Parenteral nutrition:

• Indicated for high-output fistulae, prolonged ileus, short bowel syndrome, and severe malnutrition when enteral nutrition has failed 5
• Use as adjunctive therapy in complex fistulating disease 5
• Consider for intra-abdominal abscess with phlegmonous inflammation as bridge to surgery 5

Dietary Recommendations for Remission

All IBD patients should follow a Mediterranean diet rich in fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins, while avoiding ultraprocessed foods, added sugar, and salt 5

For patients with intestinal strictures:

• Emphasize careful chewing and cooking fruits/vegetables to soft consistency to improve tolerance 5
• This allows incorporation of plant-based foods despite strictures 5

Critical Warnings and Pitfalls

Corticosteroid management:

• Never use corticosteroids for maintenance therapy in CD 8
• Rapid steroid reduction is associated with early relapse; taper gradually over 8 weeks 5
• Maximum duration for systemic corticosteroids is 8 weeks 8

Immunomodulator risks:

• Fatal hepatosplenic T-cell lymphoma (HSTCL) reported in patients receiving azathioprine or 6-mercaptopurine with TNF-blockers, particularly adolescent/young adult males with CD or UC 10
• Carefully assess risk/benefit before combining these agents 10

Infliximab precautions:

• Test for latent TB before starting infliximab; if positive, treat TB first 10
• Monitor all patients for active TB during treatment, even if initial test negative 10
• Increased risk of serious infections including bacterial sepsis and invasive fungal infections 10
• Discontinue if serious infection develops 10

Severe UC management:

• Do not delay corticosteroid therapy while awaiting stool microbiology results 5, 7
• Maintain close liaison with colorectal surgeon from admission 5
• Patients should be informed of 25-30% chance of needing colectomy 5

Multidisciplinary Team Approach

Essential team members include:

• Gastroenterologists with IBD expertise 8
• Colorectal surgeons for joint management of severe cases 5, 8
• Registered dietitians as essential part of interdisciplinary team for optimal nutrition assessment and management 5

Cancer Surveillance

Colonoscopy after 8-10 years to re-evaluate disease extent, with surveillance decisions individualized based on patient risk factors 6, 8