Inflammatory Bowel Disease

Meet the patient

A 32-year-old primary school teacher arrives with six weeks of bloody diarrhoea — eight to ten stools a day — cramping lower abdominal pain, urgency, and four kilograms of weight loss. She has known ulcerative colitis, pancolitis for six years, on mesalazine two grams daily. Her shins are covered in tender red nodules, both knees are swollen, and her heart rate is ninety-six.[1]

The three questions that decide her next seventy-two hours are the three that decide every IBD flare: is this infection or flare? (send the stool), how severe? (Truelove and Witts), and what is the exit strategy from steroids? (mucosal healing, not symptom control). Hold those three and the entire management ladder falls into place.[1]

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1. [1]Khor B, Gardet A, Xavier RJ Genetics and pathogenesis of inflammatory bowel disease Nature, 2011.PMID 21677747
2. [2]Colombel JF, Sandborn WJ, Reinisch W, et al. Infliximab, azathioprine, or combination therapy for Crohn's disease N Engl J Med, 2010.PMID 20393175
3. [3]Rutgeerts P, Sandborn WJ, Feagan BG, et al. Infliximab for induction and maintenance therapy for ulcerative colitis N Engl J Med, 2005.PMID 16339095
4. [4]Järnerot G, Hertervig E, Friis-Liby I, et al. Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study Gastroenterology, 2005.PMID 15940615
5. [5]Laharie D, Bourreille A, Branche J, et al. Ciclosporin versus infliximab in patients with severe ulcerative colitis refractory to intravenous steroids: a parallel, open-label randomised controlled trial Lancet, 2012.PMID 23063316
6. [6]Feagan BG, Sandborn WJ, Gasink C, et al. Ustekinumab as Induction and Maintenance Therapy for Crohn's Disease N Engl J Med, 2016.PMID 27959607
7. [7]Feagan BG, Rutgeerts P, Sands BE, et al. Vedolizumab as induction and maintenance therapy for ulcerative colitis N Engl J Med, 2013.PMID 23964932
8. [8]Sandborn WJ, Su C, Sands BE, et al. Tofacitinib as Induction and Maintenance Therapy for Ulcerative Colitis N Engl J Med, 2017.PMID 28467869
9. [9]Menees SB, Powell C, Kurlander J, et al. A meta-analysis of the utility of C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin to exclude inflammatory bowel disease in adults with IBS Am J Gastroenterol, 2015.PMID 25732419
10. [10]Turner D, Ricciuto A, Lewis A, et al. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD Gastroenterology, 2021.PMID 33359090