Inflammatory Bowel Diseases

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

Investigations 

• Endoscopic evidence of diffuse and continuous colonic mucosal inflammation with friability and loss of mucosal vascularity characteristic cobble stone appearance.
• Histologic evidence of abnormal crypt architecture and superficial inflammation typical of UC.

Pharmacological Treatment 

D: sulfasalazine (PO) 1000mg 6hourly a day for acute disease, reducing to 1000mg once daily for maintenance   

OR 

S:  mesalazine  (PO)  1.5g–4g/day  in  divided  doses  reduced  to  0.75–2g  g/day  in  divided doses for maintenance 

AND  

A: prednisolone (PO) 30–60mg 24hourly for severe, acute and extensive disease; tapering  gradually after induction of remission within 8 weeks. 

For severe disease flares give IV corticosteroids, 

D: methylprednisolone (IV) 16-20mg 8hourly 5- 7days 

If  irresponsive  (i.e.  fewer  stools,  less  bleeding)  to  IV  corticosteroids  for  5-7days,  or  acute  complications give the following; 

S: cyclosporine (IV) 2-4mg/kg 12hourly for 7days 

THEN change to  

S: azathioprine (PO) 1.5-2.5 mg/kg 24hourly for maintenance. 

OR  

S: infliximab (IV) 5 mg/kg at 0, 2, and 6weeks, then every 8weeks 

Note: Complication of UC may present with massive haemorrhage, toxic mega colon, AND perforation with  features  of  peritonitis  necessitates  hospitalization.  Colonoscopy  with  random  biopsy  8  years  after  diagnosis to evaluate for dysplasia, every 1-3 years thereafter based on risk factors. Use steroids only  when the disease is confirmed and for induction of remission only. 

Crohn’s disease is an idiopathic, chronic, transmural inflammatory process of the bowel that often  leads to fibrosis and obstructive symptoms and can affect any part of the gastrointestinal tract from  the mouth to the anus. 

Clinical presentation

• Abdominal pain, diarrhea, weight loss, anorexia and fever
• Gross rectal bleeding or acute hemorrhage is uncommon
• Anemia due to illeal disease involvement
• Small bowel obstruction, due to structuring
• Perianal disease associated with fistulization
• Gastroduodenal ulceration

Investigations 

• Endoscopic evidence of rectal sparing skip lesions, cobble stoning with linear ulceration appearance with,
• Histological evidence of transmural disease, aphthous ulcers, and non-caseating granulomas

Pharmacological Treatment 

S: methotrexate (PO) 7.5–15mg weekly 

OR 

S: azathioprine (PO) 50mg 24hourly for maintenance of remission. 

AND  

A: prednisolone (PO) 1–2mg/kg for induction of remission only (Taper in 8 weeks) 

AND 

A: metronidazole (PO) 400mg 8hourly for 7–10days  

OR 

A: ciprofloxacin (PO) 500mg 12hourly for 7–10days – can be added in presence of perianal disease or evident septic complications. 

For severe disease flare or acute complications  

Patients who have had inadequate response to conventional therapy, also for reducing the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure in adult patients  with fistulizing Crohn disease. 

S: infliximab (IV) 5 mg/kg at 0, 2, and 6 weeks, THEN every 8weeks thereafter 

AND  

S: azathioprine (PO) 1.5-2.5 mg/kg 24hourly 

Note: Resuscitative and supportive management should be instituted as for UC section note above.