Inflammatory Bowel Disease Management
On this page
Direct answer
Ulcerative colitis and Crohn's disease are lifelong relapsing diseases managed by matching drug intensity to disease extent and severity: mesalazine 2-4 g daily, orally plus topical for distal ulcerative colitis; prednisolone 40 mg daily for flares, never as maintenance; azathioprine 2-2.5 mg/kg daily or biologics for steroid-dependent or refractory disease. Acute severe ulcerative colitis — more than six bloody stools daily plus systemic toxicity (Truelove-Witts criteria) — is an admission for intravenous hydrocortisone 100 mg four times a day, with stool testing for Clostridioides difficile and cytomegalovirus, and day-three assessment (Oxford criteria) deciding between ciclosporin or infliximab rescue and colectomy. Crohn's disease favours the top-down view: steroids for induction, immunomodulators and anti-TNF agents for maintenance, smoking cessation, and surgery reserved for complications.
What you must remember
- Extent decides delivery: proctitis — mesalazine suppositories (1 g nightly) beat oral; left-sided — oral 2-4 g plus topical; extensive — oral therapy with or without topical.
- Steroid rules: prednisolone about 40 mg (0.5-1 mg/kg) tapered over 8-10 weeks for a flare; dependence or relapse on tapering signals the need for a thiopurine or biologic — steroids never maintain remission.
- Thiopurine discipline: azathioprine 2-2.5 mg/kg daily (6-mercaptopurine alternative); check full blood count and liver profile regularly; counsel on the weeks-long onset; TPMT screening where available.
- Biologic entry points: infliximab 5 mg/kg at weeks 0, 2 and 6 then 8-weekly, or adalimumab, for steroid-refractory or fistulating Crohn's and moderate-to-severe uc — screen for latent tuberculosis under NTEP guidelines first.
- Acute severe UC: Truelove-Witts — six or more bloody stools plus tachycardia, fever, anaemia or raised ESR/CRP; admit, IV hydrocortisone 100 mg QDS, exclude infection, anticoagulate.
- Day-three rescue: Oxford criteria — more than eight stools, or three to eight with CRP above 45 — predicts steroid failure and triggers ciclosporin or infliximab versus colectomy.
- Crohn's specifics: ileocaecal disease may need budesonide or steroids; stricturing disease avoids fibrosis-worsening approaches; fistulae need anti-TNF with or without seton drainage; smoking genuinely worsens Crohn's (and, oddly, protects against UC).
- Surgery's place: panproctocolectomy cures ulcerative colitis (ileal pouch in selected cases); Crohn's surgery is conservative and segmental because recurrence is the rule at the anastomosis.
How to work through an acute severe flare
A 29-year-old with known left-sided ulcerative colitis on mesalazine reports nine bloody stools overnight, fever of 38.2°C and a pulse of 104. This meets Truelove-Witts severity: admit, nothing by mouth as needed, intravenous hydrocortisone 100 mg four times a day, fluid and transfusion support, and low-molecular-weight heparin — thromboprophylaxis is standard because inflamed colitis is prothrombotic. Before escalating immunosuppression, the stool is tested for C. difficile toxin and colonoscopic biopsies checked for cytomegalovirus inclusion bodies; either infection mimics refractory colitis and treating it reverses the picture without escalation.
Day three is decision day: he still passes eight stools and the CRP is 60 — Oxford criteria met — so watchful waiting ends. The choices are intravenous ciclosporin 2 mg/kg or infliximab 5 mg/kg as rescue, with colectomy counselled in parallel for toxic megacolon (transverse colon over 6 cm), perforation or refractory haemorrhage. He responds to infliximab, converts to oral therapy, and leaves on azathioprine maintenance with a plan for maintenance biologics — and with a clear understanding that colectomy, should it ever come, is a cure, not a failure.
How the FMGE frames it
NBE discriminates uc from Crohn's using the old anatomical clues — continuous mucosal inflammation from the rectum upwards with crypt abscesses versus skip lesions, transmural inflammation, creeping fat and non-caseating granulomas — then tests management by extent (suppository for proctitis is a classic keyed answer). Steroid-related questions dominate: the drug that induces but never maintains, the dose for a flare, and the rescue agents for acute severe disease. The Indian layer is tuberculosis: before any anti-TNF therapy, screening for latent TB (chest radiograph, tuberculin or interferon-gamma assay under NTEP guidance) is mandatory, and a fistula in this country must first have its tubercular and malignant differentials excluded. Toxic megacolon width (6 cm) and the Oxford day-three rules are quoted as numbers, and the "smoking worsens Crohn's" paradox appears often enough to be free marks.
Frequently asked questions
What defines acute severe ulcerative colitis?
Six or more bloody stools per day plus at least one of tachycardia over 90, fever above 37.8°C, anaemia or raised inflammatory markers (Truelove-Witts criteria).
Which delivery of mesalazine is best for ulcerative proctitis?
Topical therapy — mesalazine suppository 1 g nightly — outperforms oral therapy alone for distal disease.
Why are corticosteroids never maintenance therapy?
They induce remission but do not prevent relapse, and long-term use causes diabetes, osteoporosis and infection; steroid dependence mandates azathioprine or a biologic.
What must be excluded before escalating immunosuppression in refractory colitis?
Clostridioides difficile infection and cytomegalovirus colitis, both of which mimic steroid-refractory disease and are treated as infections first.
Which screening precedes anti-TNF therapy in India?
Latent tuberculosis screening — chest radiograph with tuberculin or interferon-gamma release testing and appropriate prophylaxis under NTEP guidance — because anti-TNF drugs reactivate tuberculosis.