Management of Inflammatory Bowel Disease (Ulcerative Colitis and Crohn's Disease) 

What Is The Most Common Clinical Presentation Of IBD?

• UC - Diarrhea - Bloody
• CD - Abdominal pain

Pain due to inflammation and fibrosis and stenosis.

Endoscopic Findings

In UC -Initially Ulcers May Or May Not Be Seen

• The vasculature is seen in normal individuals, In UC -

There is a loss of vascularity. The ulcers in UC are superficial.  Restricted to mucosa and submucosa. Due to edema of mucosa and inflammatory regeneration → It leads to the formation of pseudopolyps

• In UC - after treatment - Due to regeneration the healed areas may be confused as skip lesions.

Backwash ileitis

• In around 15 % of patients of UC - There is some degree of involvement in the terminal ileum, but this has no clinical consequence. This may be due to the inflammatory mediators escaping into the terminal ileum. The disease begins in the rectum and progresses proximally. 
• CD - can occur in any part of the GI system - From the oral cavity to the rectum. In UC-Oral ulcers are considered an extraintestinal manifestation.

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Complications Of Inflammatory Bowel Disease

Toxic Megacolon

• Commonly associated with Ulcerative colitis > Crohns disease. Presents with toxic features and distended colon. Due to distended colon- Abdominal pain, Abdominal distension. On abdominal X-ray erect - right side of the colon or transverse colon is distended - > 6 cm diameter.

Toxic Features

• Fever, Toxic look, Tachycardia, Tachypnoea, Diaphoresis. Fever is more common with Crohns disease. So, if a Ulcerative colitis patient presents with a fever think of Toxic megacolon and Intercurrent Infections. Toxic megacolon suggests that the disease activity is high. The walls are also friable and may lead to perforation. This leads to perforation peritonitis and increased risk of mortality.

Management Of Ulcerative Colitis

STEP 1 

• Categorize into mild/moderate/severe cases- based on Modified Truelove and Witts criteria, it is important so we can decide on use of systemic therapy. 

Step 2 

• If it is mild, identify the disease extent - based on Montreal classification. This helps in choosing between rectal and oral routes of medications. If the disease is restricted to the rectum, rectal suppositories are best for management. 

Step 3 

• Suitable treatment 

Step 1 - Modified Truelove and Witts criteria

Step 2 - Montreal Classification 

Based on colonoscopy findings- E1- restricted to rectum, E2 - Up to splenic flexure, E3- beyond splenic flexure. So in mild disease, if the extent is E1 - topical therapy is better than oral, E2- oral + topical and E3- Oral 士 topical.

Step 3 – Treatment

• Mild – Mesalamine- E1 – topical, E2 and E3 – oral. If patients do not respond to mesalamine → oral steroids 
• Moderate- Step-up approach- Oral mesalamine, oral steroids. Biologicals if steroid non-responsive- Anti-TNF 
• Severe- Requires admission, Hydration – IV, IV steroids-IV hydrocortisone 400 mg/day, IV methylprednisolone 60 mg/ day. Maintain thiopurines. If no response - aggressive immunosuppression
  • Infliximab - 5mg/kg
  • Cyclosporine - 2mg/kg/day 
  • Surgical 

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Management Of Crohn’s Disease

• Step 1 - Classification of severity- Based on Vienna and Montreal classification
• Step 2 - Appropriate management based on disease behavior

Step 1 - Vienna and Montreal classification

• L4 is a modifier: L4 can be added to other parameters. Suppose the patient is diagnosed at 35 years and there is ileal involvement and upper involvement. Then the category becomes - A2 L1 L4. If there is a fistula or penetrating disease and there is a perianal disease. Then the overall category becomes - A2 L1 L4 B3p
• This category also helps in identifying the disease course over the years. For Crohns disease, we follow either step up approach or a top-down approach. In a top-down approach, we start the treatment with potent drugs for remission
• B1 - step-up approach: B2 and B3 - top-down approach 

• B1 - sulfasalazine - non-absorbable, non-systemic corticosteroids. B2 - induction - corticosteroids / anti – TNF. Maintenance with anti - TNF / thiopuriens/ methotrexate. B3 - induction with anti - TNF / surgical. Maintenance with anti - TNF / azathioprine/ methotrexate
• USTEKINUMAB - is a reserved drug.

Hope you found this blog helpful for your NEET SS Gastroenterology and Hepatobiliary preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.