Inflammatory bowel diseases management

Inflammatory bowel diseases management

Inflammatory bowel disease (IBD) is an idiopathic disease involving an immune reaction of the body to its own intestinal tract.

The two major types of IBD are:

• Ulcerative colitis (UC)

• Crohn's disease (CD)

Pathologically, ulcerative colitis is limited to the colon, whereas Crohn's disease can involve any segment of the gastrointestinal tract from the mouth to the anus.

Ulcerative colitis (UC)

Ulcerative colitis is an inflammatory condition that involves the rectum and extends proximally to affect a variable extent of the colon up to the caecum.

Clinical presentation

• Diarrhoea

• Rectal bleeding

• Tenesmus

• Passage of mucus

• Crampy abdominal pain

• Fever

• Chills

Investigations

Endoscopy

• Endoscopic evidence of diffuse and continuous colonic mucosal inflammation with friability and loss of mucosal vascularity.

• Characteristic cobblestone appearance.

Histopathology

• Histological evidence of abnormal crypt architecture and superficial inflammation typical of ulcerative colitis.

Pharmacological treatment

Mild to moderate disease

• Sulfasalazine (PO) 1000 mg every 6 hours for acute disease, reducing to 1000 mg once daily for maintenance

OR

• Mesalazine (PO) 1.5–4 g/day in divided doses, reduced to 0.75–2 g/day in divided doses for maintenance

Severe, acute, or extensive disease

Add:

• Prednisolone (PO) 30–60 mg every 24 hours

Taper gradually after induction of remission within 8 weeks.

Severe disease flare

• Methylprednisolone (IV) 16–20 mg every 8 hours for 5–7 days

Steroid-refractory disease or acute complications

If there is no response to intravenous corticosteroids after 5–7 days (e.g., persistent frequent stools and bleeding), or if acute complications develop:

Cyclosporine-based regimen

• Cyclosporine (IV) 2–4 mg/kg every 12 hours for 7 days

THEN

• Azathioprine (PO) 1.5–2.5 mg/kg every 24 hours for maintenance

OR

Biologic therapy

• Infliximab (IV) 5 mg/kg at weeks 0, 2, and 6, then every 8 weeks

Monitoring and follow-up

Colon cancer surveillance

• Colonoscopy with random biopsy should be performed 8 years after diagnosis to evaluate for dysplasia.

• Repeat surveillance colonoscopy every 1–3 years thereafter according to risk factors.

Complications

Complications of ulcerative colitis may include:

• Massive haemorrhage

• Toxic megacolon

• Perforation with features of peritonitis

These complications necessitate hospitalization.