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

Medical care of patients with inflammatory bowel disease (IBD) comprises general measures and specific pharmacological, nutritional, endoscopic and surgical therapies (Table ​(Table11)[1-3]. In this paper, current management options for patients with two commonly difficult presentations of IBD, acute severe ulcerative colitis (UC) and steroid-refractory or dependent ileocaecal Crohn's disease (CD), are discussed. Practical considerations and newer developments are emphasized. Table 1 Principles of management of acute severe ulcerative colitis MANAGEMENT OF ACUTE SEVERE ULCERATIVE COLITIS These patients should be admitted immediately to a gastroenterology ward for close joint medical, surgical and nursing care. The nutrition team and a stoma therapist in patients likely to need surgery should be involved promptly. Patients undergoing an acute attack of UC need to be made aware from the outset that they have a one in four chance of failing to respond to the primary treatment (intravenous steroids), and thus need either cyclosporin or colectomy during their admission (Table ​(Table11). Establishing the diagnosis, extent and severity of disease A carefully targeted history and appropriate investigations can help establish the diagnosis (Table ​(Table2)2) in patients presenting for the first time and, in those with established UC, to exclude infection and to assess disease extent (if not already known) and severity. Table 2 Management of active ileocaecal Crohn's disease. General measures, monitoring progress and supportive treatment are essentially as for ulcerative colitis Blood and stool tests Stool should be sent to look for pathogens, and serology checked for amoebiasis, strongyloidiasis and schistosomiasis. Blood tests are better for establishing the activity of UC than making the diagnosis or identifying its extent. However, a raised platelet count is more common in UC than in infective colitis. The best measures of disease activity are haemoglobin, platelet count, ESR, C-reactive protein[4] and serum albumin. Sigmoidoscopy and rectal biopsy Cautious rigid or flexible sigmoidoscopy in the unprepared patient, and without excessive air insufflation, provides immediate confirmation of active colitis. Sigmoidoscopy also allows biopsy for histology: to minimise the risks of bleeding and perforation a small superficial biopsy should be taken from the posterior rectal wall less than 10 cm from the anal margin using small-cupped forceps. Anecdotally, colonoscopy may cause colonic perforation and dilatation in acute severe UC, and although some authorities have reported that it is both safe and useful for decision-making[5], most patients can be managed satisfactorily without it. In patients with established UC, rectal biopsy is not routinely necessary. However, in those presenting for the first time, infective colitis may be suggested by an acute, focal and superficial inflammatory infiltrate with minimal goblet cell depletion and preservation of crypt architecture[6]. Although colitis due to Clostridium difficile, cytomegalovirus, amoebiasis and Crohn's disease often has characteristic macroscopic appearances, histology may confirm these diagnoses. Plain abdominal X-ray A plain film at presentation can be used to assess disease extent, since faecal residual visible on X-ray usually indicates sites of uninflamed colonic mucosa. Plain abdominal X-ray is also used to assess disease severity and in particular to exclude colonic dilatation (diameter > 5.5 cm) in sick patients, however, the gas pattern on a plain film may be misleading if there has been excessive air insufflation during a sigmo idoscopy or colonoscopy done shortly beforehand. In patients with suspected colonic perforation, the diagnosis can be confirmed by erect chest X-ray or a later al decubitus abdominal film. Radiolabelled leucocyte scans The intensity and extent of colonic uptake one hour after injection of autologous 99Tc-HMPAO or 111Indium-labelled leukocytes provides information about disease activity and particularly extent, respectively, where doubt exists in patients with UC. Colonic uptake of leucocytes is not of course specific for UC and positive results are obtained in other inflammatory colonic diseases.