Inflammatory bowel disease

Borders Ref Help Toolkit (in development)
NHS Borders

IBD Patient Advice Line (01896 826454)- This should be the patients first contact for a flare of known IBD. This number can also be contacted by primary care for advice on patient’s not requiring hospital admission.

For non-urgent advice please contact: gastroenterology.nursespecialists@borders.scot.nhs.uk

Crohn’s disease

The treatment of Crohn’s Disease is defined by extent, severity and behaviour. Extent is subdivided into colonic, small bowel or both, with or without perianal or upper GI disease. Severity of inflammation can be difficult to define in Crohn’s Disease: - clinically defined as stool frequency, abdominal pain and wellbeing but symptoms may be a poor indicator of gut inflammation - A commonly used index is Harvey-Bradshaw index (see below)

Number of liquid stools/day General wellbeing Abdominal pain Abdominal mass Complications (Add 1 point for each)
Score 1 for each Very well =0 None = 0 None = 0 Arthralgia
  Slightly below par = 1 Mild = 1 Definite = 1 Uveitis
  Poor = 2 Moderate = 2 Dubious = 2 Erythema nodosum
  Very poor = 3 Severe = 3 Definite & tender = 3 Aphthous ulcers
  Terrible = 4     Pyoderma gangrenosum
        Anal fissure
        New fistula
        Abscess

 

Score interpretation: <5 = remission, 5-7 = Mild disease, 8-16 = Moderate disease, >16 = Severe disease

 

Ulcerative colitis

The severity of disease in ulcerative colitis determines the management.

 

  Bloody stools per day Systemic disturbance (Fever, HR >90, Hb <105, CRP >30
Mild <4 No
Moderate 4-5 No 
Severe >5 Yes

 

Who to refer:

Patients who are believed to be having a flare of IBD can be discussed with GI nurse specialists if advice is needed.

Patients with severe symptoms should be admitted to hospital.

Patients who are new to the area with known IBD but who are not experiencing a flare can be routinely referred to gastroenterology via SCI gateway.

 

Who not to refer:

Patients with IBD who are felt to have other pathology unrelated to their IBD.

 

How to refer:

Patients who require admission to hospital should be discussed with the medical registrar on call.

 

All patients with a suspected flare of IBD should have:

  • Stool cultures- including C.Diff (and OCP if travel history)
  • Blood tests- FBC, U&E, LFT, Calcium/albumin, CRP
  • Faecal calprotectin

Crohn’s disease

Management is based on the degree of disease and the location of the patient’s disease:

Colonic Crohn’s disease Mild Moderate Severe
 
  • Consider giving no treatment
  • If faecal testing is normal, consider concurrent IBS
  • Repeat faecal testing at 3 months
  • Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg/week to 0
  • Budesonide 9 mg od for 6 weeks is an alternative for Prednisolone intolerant patients with inflammation in right and transverse colon
  • Engage local IBD Service at early stage

 

Admit to hospital
Ileo-colonic crohn’s disease
  • Consider giving no treatment
  • If faecal testing is normal, consider concurrent IBS If previous ileal resection consider bile salt malabsorption and give Cholestryamine 4 g bd.
  • Repeat faecal testing at 3 months
  • Budesonide 9 mg od for 6 weeks then 6 mg od for 1 week, then 3 mg od for 1 week, then stop.
  • If no response, Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg per week to 0.
  • Polymeric diet is an alternative to steroids.
  • Engage local IBD Service at early stage

 

Admit to hospital
Extensive small bowel disease Mild disease Moderate disease Severe disease
 
  • Low residue diet. Consider giving no treatment.
  • If faecal testing is normal, consider concurrent IBS
  • Repeat faecal testing at 3 months
  • Engage local IBD Service for advice at early stage
  • Polymeric diet: discuss with secondary care and refer to dietitian.
  • Budesonide 9 mg od for 6 weeks, then 6 mg od for 1 week, then 3 mg od for 1 week, then stop.
  • If no response, Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg per week to 0.
  • Polymeric diet is an alternative to steroids.
  • Engage local IBD Service at early stage
 Admit to hospital
Perianal disease Mild Moderate Severe
  Assess temperature, inspect perineum and do rectal examination. Is there any sepsis present? As a general rule, if the patient is unable to sit properly they should be referred
  • Give Metronidazole or Ciprofloxacin for 14 days in the first instance
  • Most patients will need a MRI or an EUA – engage with local IBD Service at an early stage
 Admit to hospital

 

Ulcerative colitits

Management is based on severity

 

Proctitis Mild/moderate   Severe
 
  • Salofalk suppositories 1 g nocte, steroid suppository if mesalazine intolerant
  • If no response after 2 weeks, add oral Salofalk 1.5 - 3g/day
  • If deterioration, consider Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg per week to 0
  • Engage with local IBD Service at early stage
   Admit to hospital
Left sided colitis Mild Moderate Severe
 
  • Give oral Salofalk 1.5-3g /day OR Salofalk liquid enema 2 g nocte, steroid enema if mesalazine intolerant
  • If no response, give both oral Salofalk and Salofalk liquid enema
  • If still no response, add Prednisolone 40 mg od for 2 weeks, then reduce dose by 5 mg per week to 0
  • Engage with local IBD Service at early stage
  • Give oral Salofalk 1.5-3g /day AND Salofalk liquid enema 2 g nocte
  • If no response, add Prednisolone 40 mg od for 2 weeks, then reduce dose by 5 mg per week to 0
Engage with local IBD Service at early stage		 Admit to hospital
Extensive/Pan colitis Mild/moderate   Severe
 
  • Give Mesalazine Salofalk 1.5-3g /day
  • If no response, add Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg per week to 0.
  • Engage with local IBD Service at early stage
   Admit to hospital

 

 

 

For non-urgent advice please contact: gastroenterology.nursespecialists@borders.scot.nhs.uk 

Editorial Information

Author(s): Jonathan Fletcher, Angus Wallace.

Author email(s): bor.gastroenterology@borders.scot.nhs.uk.