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

Table 2 Management of active ileocaecal Crohn's disease. General measures, monitoring progress and supportive treatment are essentially as for ulcerative colitis

ESTABLISHING THE DIAGNOSIS, EXTENT/SITE AND SEVERITY

- clinical evaluation

- FBC, ESR, C-reactive protein, ferritin, folate, B12, albumin, LFTs, Ca, Mg, Zn

- stool microscopy, culture, C difficile toxin

- plain abdominal X-ray

- consider colonoscopy and biopsy, small bowel barium radiology, ultrasound, CT, MRI, leucocyte scan

SPECIFIC TREATMENT (separately or in combination)

Medical - corticosteroids i.v. (hydrocortisone or methyl prednisolone) then p.o. (prednisolone or budesonide CR)

- continue high dose mesalazine (Pentasa or Asacol) in patients already taking it; otherwise start when improvement begins

- consider metronidazole, ciprofloxacin; also broad spectrum antibiotics for very sick febrile patients, or when infection/collection suspected

- consider azathioprine/6-mercaptopurine (slow response) or anti TNF antibodies (infliximab) for steroid non-responders

Nutritional - liquid formula diet

Endoscopic - balloon dilatation

Surgical - resection or stricturoplasty