How Can We Help?
Inflammatory bowel disease
Background
There are variations in referral patterns and perhaps also in disease patterns which lead to differences in frequency of inflammatory bowel disease in different regions.
The three main diseases are ulcerative colitis, Crohn’s disease, and infectious processes masquerading as one or other of the former.
Ulcerative colitis
Usually presents with diarrhoea, abdominal pain and rectal urgency or tenesmus. Barium enema show suggestive features, and gives some idea of the extent of the process, but sigmoidoscopy with biopsy is the investigation of choice. Colonoscopy is not necessary on presentation, although it may be used later to help delineate the extent of the disease and as a cancer screening tool. At sigmoidoscopy there is simply evidence of colitis with an abnormal mucosa and easy bleeding. Histology shows superficial inflammatory changes and crypt abscesses.
Differential diagnosis is broad, but includes all the causes of infectious colitis, ischaemic colitis, and in predominant rectal disease, STDs such as syphilis, gonorrhoea and LGV.
Other investigations:
- Stool MC&S.
- Stool for Clostridium difficile if the patient has been on antibiotics.
- FBC.
- Albumin and total protein plus liver enzymes.
- CRP.
Treatment is with sulphasalazine 500 mg 12 hourly, increasing to 500 mg 8 hourly and then 1g 12 hourly. (It is reasonable to start with higher doses – e.g. 1g 4x/d – during an acute attack.) Prednisone 1 mg/kg per day (higher doses don’t show much incremental benefit) may help induce remission in 2 or 3 weeks, but should be weaned reasonably quickly, at a rate of 5 mg per week, and should not be used long term in high doses. More severe cases obviously would benefit from referral, where consideration will be given to the use of azathioprine or other immunosuppressants. Surgery is indicated for intractable disease.
Complications of ulcerative colitis
Toxic megacolon – usually a sick patient with abdominal distension readily identified on plain X-Ray as due to bowel. The unwary may confuse with sigmoid volvulus – if in doubt ask the surgeons to look rather than making facile value judgements. Should settle with drip and suck and intravenous steroids (hydrocortisone 100 mg 6 hourly) within 24 hours, but ask the surgeons to see early, and in particular if there are any suggestions of perforation.
Rectal bleeding – transfuse; if doesn’t settle after 2 or 3 units then refer to the surgeons.
Perforation. Keep an open mind, particularly in patients on steroids where the signs of peritonitis may be masked. Involve a surgeon early if in any doubt.
In patients who are not settling, also consider concurrent infective causes (blood culture, stool MC&S, stool for Clostridium difficile assay).
Signs that a patient is settling on treatment are mainly clinical – falling pulse rate, reduced stool frequency, and settling temperature.
Crohn’s disease
This is predominantly a terminal ileal inflammatory process which is quite rare in poorer communities. Diagnosis is by barium enema and biopsy, and management is broadly similar to ulcerative colitis, with prednisone and sulphasalzine. Patients with terminal ileal disease should be considered for vitamin B12: 1 mg IM every 3 months.
Other inflammatory and toxic colitides
Apart from HIV associated infective colitis which may be due to a host of organisms (send stool for MC&S, and consider empiric antibiotic therapy in the very ill, e.g. with ciprofloxacin or an IV third generation cephalosporin), colonic and rectal inflammation secondary to use of traditional medication, particularly herbal enemas, is quite common, and should be considered in any patient presenting with bloody diarrhoea. It usually resolves quickly with supportive management, but don’t forget to look for the underlying disease that might have led to the enema’s use.