# Inflammatory Bowel Disease Management

> Inflammatory bowel disease management for FMGE Medicine: mesalazine dosing, steroid flares, thiopurine monitoring and acute severe ulcerative colitis rescue.

- Canonical URL: https://prepelephant.com/topics/fmge/medicine/inflammatory-bowel-disease-management
- Exam / course: FMGE · Subject: Medicine
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Inflammatory Bowel Disease Management", PrepElephant, https://prepelephant.com/topics/fmge/medicine/inflammatory-bowel-disease-management

## 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.