Management of difficult inflammatory bowel disease: where are we now?

Table 1 Principles of management of acute severe ulcerative colitis

GENERAL MEASURES

Explanation, psychosocial support

- patient support groups

Specialist multidisciplinary care

- physicians, surgeons, nutrition team, nurses, stoma therapist, counsellor

ESTABLISHING THE DIAGNOSIS, EXTENT/SITE AND SEVERITY

- clinical evaluation

- FBC, ESR, C reactive protein, albumin, LFTs, amoebic serology

- stool microscopy, culture, C. difficile toxin

- limited sigmoidoscopy and biopsy

- plain abdominal X-ray

- consider radiolabelled leucocyte scan

MONITORING PROGRESS

- daily clinical assessment

- stool chart

- 4-hrly temperature, pulse

- daily FBC, ESR, C-reactive protein, urea and electrolytes, albumin

- daily plain abdominal X-ray

SUPPORTIVE TREATMENT

- i.v. fluids, electrolytes (Na, K), blood transfusion

- nutritional supplementation

- heparin s.c.

- haematinics (folate)

-avoid antidiarrhoeals (codeine, loperamide, diphenoxylate), opiates, NSAIDs

- rolling manoeuvre (if colon dilating)

SPECIFIC TREATMENT

Medical - corticosteroids i.v. (hydrocortisone or methylprednisolone) then p.o. (prednisolone)

-continue 5-ASA p.o. in patients already taking it; otherwise start when improvement begins

-antibiotics for very sick febrile patients, or when infection suspected

-consider cyclosporin i.v. then p.o.) for steroid non-responders at 4-7 d

Surgical (for non-responders at 5-7 d, toxic megacolon, perforation, massive haemorrhage)

- panproctocolectomy with ileoanal pouch or permanent ileostomy

- subtotal colectomy with ileorectal anastomosis (rarely)

Table 2 Management of active ileocaecal Crohn's disease. General measures, monitoring progress and supportive treatment are essentially as for ulcerative colitis

ESTABLISHING THE DIAGNOSIS, EXTENT/SITE AND SEVERITY

- clinical evaluation

- FBC, ESR, C-reactive protein, ferritin, folate, B12, albumin, LFTs, Ca, Mg, Zn

- stool microscopy, culture, C difficile toxin

- plain abdominal X-ray

- consider colonoscopy and biopsy, small bowel barium radiology, ultrasound, CT, MRI, leucocyte scan

SPECIFIC TREATMENT (separately or in combination)

Medical - corticosteroids i.v. (hydrocortisone or methyl prednisolone) then p.o. (prednisolone or budesonide CR)

- continue high dose mesalazine (Pentasa or Asacol) in patients already taking it; otherwise start when improvement begins

- consider metronidazole, ciprofloxacin; also broad spectrum antibiotics for very sick febrile patients, or when infection/collection suspected

- consider azathioprine/6-mercaptopurine (slow response) or anti TNF antibodies (infliximab) for steroid non-responders

Nutritional - liquid formula diet

Endoscopic - balloon dilatation

Surgical - resection or stricturoplasty