Diarrhoea • THEME

Inflammatory
bowel disease

BACKGROUND Inflammatory bowel disease T he past 40 years have seen inflammatory bowel
(IBD) is increasing in frequency in Australia. disease (IBD) move from a boutique oddity to a
General practitioners play an important role relatively common illness.1 It is estimated that up to
in early diagnosis and in a multidisciplinary 10 000 people are affected in Australia. There is an
approach to managing such patients. Keeping approximately equal distribution of the two clinically
abreast of evolving concepts, particularly in definable entities, ulcerative colitis and Crohn disease Peter R Gibson,
treatment, is challenging. (CD); although in 15% of patients with colitis, the MD, FRACP, is
Professor of
OBJECTIVE This article aims to address key distinction is not clear and these patients are classified
Gastroenterology,
issues in diagnosis and management to better as having indeterminate colitis. Inflammatory bowel Monash University,
equip general practitioners for their role in disease is characterised by chronic inflammation in and Head of
multidisciplinary management of patients the gastrointestinal tract of unknown aetiology; the Gastroenterology,
Eastern Health,
with IBD. distribution being large bowel only in ulcerative colitis, IBD Clinic, Box Hill
DISCUSSION Making the diagnosis can be and most commonly ileum and colon in CD. Keeping Hospital, Victoria. peter.
abreast of the evolving concepts, particularly in gibson@med.monash.
difficult, but is facilitated by appropriate clinical
edu.au
suspicion and sensible judgment as to who treatment is challenging.
undergoes diagnostic tests such as colonoscopy.
Treatment of ulcerative colitis has changed
Making the diagnosis
little in recent years, except for our improved The clinical presentations and symptoms of IBD are
ability to deliver mesalazine to the large bowel well described. It is not uncommon for patients with
via the recent availability of several oral and IBD to describe a long diagnostic process that can take
rectal preparations. Prevention of relapse using
months or years. The key to avoid such an event is to
these is an important strategy in the majority
suspect IBD (Table 1). Almost all patients with IBD have
of patients. Treatment of Crohn disease is
bowel symptoms, ie. abdominal discomfort or pain and/
changing due to more realistic concepts of
the natural history of the disease and the or change of bowel habits (usually diarrhoea). The vast
development of new, powerful anti-inflammatory majority of patients with such symptoms however, will
have irritable bowel syndrome (IBS) and require less John Iser,
therapies. Attention to issues other than
intestinal inflammation such as nutrition, aggressive investigation. The distinguishing features are MBBS, FRACP,
is visiting
education and counselling, remain important in ‘alarm’ symptoms or signs, such as: gastroenterologist,
achieving optimal management. • rectal bleeding Eastern Health, IBD
• weight loss Clinic, Box Hill Hospital,
Victoria.
• abdominal mass
• fever
• nocturnal symptoms
• pallor, or

Reprinted from Australian Family Physician Vol. 34, No. 4, April 2005 4 233
Theme: Inflammatory bowel disease

Ulcerative colitis
Table 1. How not to miss IBD Decision making in ulcerative colitis is relatively
easy because disease distribution is easily assessed
• When diagnosis of IBS is being considered, think ‘could this be IBD?’
by colonoscopy, activity is readily evaluated on
• Beware of symptoms suggestive of acute gastroenteritis which continue
the basis of the frequency and quality of bowel
or become worse after 4 days
actions, and complications are unusual. The aim of
• Think of possible IBD for a combination of abdominal symptoms and
signs of inflammation treatment is also straightforward – to achieve and
• Think possible IBD for unexplained abdominal pain, either intermittent or maintain both clinical and histological remission. This
continuous is not unrealistic and can be achieved in at least 80%
• Insist on colonic biopsies and ileal inspection when colonoscopy is of patients.
sought for investigation of diarrhoea and/or abdominal pain Severe colitis, which is readily identified clinically
• Rectal bleeding always requires inspection – but depending on by marked frequency of bloody bowel actions together
characteristics and age, sigmoidoscopy is often sufficient with systemic symptoms in a sick patient, nearly
always requires hospitalisation for intravenous steroid
• tachycardia and possibly other therapy and will not be considered
and clues from simple screening blood tests, such as: further here. The most frequent presentation is with
• elevated C-reactive protein, white cell and/or platelet mild to moderate disease, usually involving only the
count, or erythrocyte sedimentation rate, or distal colon and rectum.
• pus cells on faecal microscopy (when bowel infection
Mesalazine
is sought but no pathogens detected).
The diagnosis is usually secured by findings at flexible The key drug in this setting is mesalazine (5-amino-
sigmoidoscopy or colonoscopy (Figure 1) that should salicylic acid, 5-ASA), which needs to be delivered
include ileoscopy if possible, together with compatible topically in large amounts to the large bowel mucosa.2,3
histopathological features on multiple biopsies. In some To do this, mesalazine can be:
patients, small bowel imaging such as by barium follow • bound to a carrier molecule – sulfapyridine for
through, is needed. Two easy ways to avoid missing sulphasalazine (Salzopyrin) and another 5-ASA
a diagnosis are to use clinical suspicion wisely, eg. molecule in olsalazine (Dipentum) – to be released
do not be deterred by normal screening blood tests within the colon via bacterial action, or
if clinical suspicion is high, and abide by the rule that • coated with a pH dependent substance (Mesasal,
chronic diarrhoea and rectal bleeding are two symptoms Salofalk) so that it is released in the terminal
warranting endoscopic examination of the large bowel. ileum and proximal colon.
Alternatively, mesalazine can be delivered directly
Treating IBD to the rectum via a suppository (Pentasa), up to
Much of the clinical decision making for patients the proximal sigmoid colon by a foam (Salofalk), or
with IBD involves how to reduce the inflammation up to the descending colon by an enema (Salofalk,
because of the potentially severe consequences of the Pentasa). Rectal preparations are usually used in
inflammation itself, and because effectively dealing with conjunction with oral mesalazine drugs, as these
this leads to gratifying improvement in most aspects of have additive efficacy in distal disease. 4
the patient’s wellbeing and quality of life. Information Mesalazine preparations are the mainst ay
that dictates choice and dose of medication is: of maintenance therapy. They will reduce the
• disease distribution chance of relapse by two-thirds, and should be
• disease severity, and recommended for long term use in all patients
• the presence and absence of complications. except those with mild proctitis. 2,3 The additional
It is not difficult to appreciate the difference in b e n e f i t ( a n d o n e ve r y i m p o r t a n t i n s e l l i n g
managing, for example, mild proctitis versus severe maintenance treatment to patients) is that
ulcerative colitis involving the entire colon, or ileal CD mesalazine protects against the development of
with obstruction versus patchy colonic CD with perianal colorectal cancer. 5 The maintenance dose needed
abscesses. As there are differences in the therapeutic is the one that prevents relapse in the individual,
approach to ulcerative colitis and CD, these will be and is often only 2 g of sulfasalazine, 1.5 g of
considered separately. coated 5-ASA, or 1 g of olsalazine per day.

234 3Reprinted from Australian Family Physician Vol. 34, No. 4, April 2005
 Theme: Inflammatory bowel disease

Corticosteroids such as haemoglobin, white cell and platelet counts,

Corticosteroids are also very effective remission serum albumin, and C-reactive protein, and, if available,
inducing agents, but carry the burden of adverse endoscopic appearances. Treatment decisions in CD are
effects. While the colorectal deliver y of rectal considerably more complex as symptoms less accurately
steroids (Predsol, Colifoam) is less of a problem, predict disease activity and complications such as perianal
they are less efficacious than rectal mesalazine. 4 disease, bowel obstruction, or abscess formation are more
Oral steroids (usually prednisolone or prednisone) common. The majority of patients should be looked upon
have the advantages of usually working relatively as having chronically active disease rather than having a
rapidly (faster than 5-ASA), and are cheap; but effects disease characterised by relapses and remissions. Healing
on body shape, bones and the psyche mean they of lesions is unusual. Furthermore, the attainment of
should be reserved for those in whom 5-ASA has ‘clinical remission’ is somewhat unreliable as patients
(or has previously had) insufficient efficacy. They chronically under-report symptoms such as tiredness
are especially indicated when colitis is on the more and easy fatigue, mainly because they have re-set their
severe end of the spectrum, or where more rapid perception of normality.
efficacy is dictated by extraneous factors. Steroids The therapeutic approach to CD is undergoing
have no role in maintenance of remission. considerable change including:
• the diminishing use of mesalazine preparations due
Immunosuppression
largely to the lack of efficacy (they still may be useful
Immunosuppressive therapy with azathioprine (or in mild disease)
6-mercaptopurine) or methotrexate is used in two • steroid use is now reserved for crisis situations, eg.
situations: while waiting the onset of action of other therapies
• in patients with chronically active disease (ie. where (azathioprine, for example, can take 3–6 months to
remission and healing of the mucosa cannot be achieve optimal efficacy)
achieved), and • antibiotics (eg. metronidazole and ciprofloxacin)
• where relapses occur more commonly than is are being used more frequently to gain control of
acceptable to the patient and doctor, despite inflammation, where previously steroids were always
mesalazine therapy at adequate doses. used (however, high level evidence for this approach
is limited7)
Surgery
• smoking cessation is now a pivotal goal of medical
Surgery for ulcerative colitis comprises removal of the intervention, as smokers are more likely to have a
rectum and the entire colon followed by possible ileal more severe and less responsive course, and these
pouch formation, and is indicated for: detrimental effects are reversible8,9
• severe, unresponsive disease • a g g r e s s i ve t h e r a py e a r l y i n t h e d i s e a s e
• chronically active disease where ongoing symptoms course, particularly with the introduction of
are incompatible with quality existence, and
• neoplastic or preneoplastic changes (dysplasia) in the exudate cobblestone pattern
large bowel.
Surgery has minimal mortality (<1%), acceptable
morbidity and the chance of a ‘cure’. Unfortunately,
an average result is 6–8 watery bowel actions per
day (but without urgency) and about one in four
patients get inflammation in the pouch (‘pouchitis’)
that requires intermittent or chronic antibiotic or
probiotic therapy. These results are highly acceptable
to patients when they compare their life before the
colectomy and pouch.6 loss of vascular pattern normal vascular linear
(oedema) pattern ulceration
Crohn disease
Figure 1. Typical colonoscopic findings in the rectum in
Assessing the activity of CD is more difficult and requires ulcerative colitis (A) compared with normal findings (B),
a combination of the clinical signs, blood markers and in Crohn disease (C)

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Theme: Inflammatory bowel disease

Table 2. Essentials on how to manage IBD – the 5 ‘EEsy’ steps Management

Management involves much more than treating the
inflammation. Optimal treatment depends as much on
Establish hierarchy of responsibility
the less tangible elements of management of a chronic
• consider whether primarily GP or specialist (gastroenterologist) care, or
whether jointly including a surgeon illness as it does on choice of drug therapy or surgery
(Table 2). Education and counselling are an important
Evaluate patient’s level of appreciation of illness
part of the management of a chronic illness. Patients
• involve ACCA (or other support organisation) if necessary
quickly recognise a limited knowledge base in doctors,
• help patient evaluate material from other sources, eg. websites
and this restricts the building of mutual respect. Thus,
Encourage patient to accept illness and to respond maturely
it is important for the primary clinician to be up-to-date
Educate patient regarding drugs and side effects and possible role of
alternative supports in disease management knowledge. Patient educative
Ensure material and counselling services are readily available
• adequate follow up via patient organisations such as The Australian Crohn’s
• nutritional needs and long term complications are being addressed and Colitis Association (ACCA).
Many of the concerns of patients with IBD are
common to most chronic illnesses in the young.
immunosuppressive therapy such as azathioprine,10 Questions regarding issues relevant to reproduction are
is often more appropriate than the traditional frequently asked – will it affect fertility or the outcome
approach of waiting to see what will be the patient’s of pregnancy, will pregnancy affect the disease course,
pattern of disease. This minimises irreversible how safe are the drugs in pregnancy and breastfeeding,
structural damage which itself might potentiate and what risk do my children have of getting IBD?
the disease and/or its symptoms (much like the While the answers to these questions are beyond the
modern approach in rheumatoid arthritis). However, scope of this article, excellent literature is available for
this aggressive approach is often limited by drug patients from ACCA.
side effects Many patients with IBD have an intense
• our abilit y to control inflammator y activit y interest in diet, but most of their advice generates
has improved markedly with the introduction of from outside the medical profession. Three out of
‘biological’ therapies such as antitumour necrosis 5 Australian patients with IBD take mineral and/or
factor (infliximab) therapy. 11 These agents have vitamin supplements, yet most of these are probably
sparked a revolution in the thinking about therapeutic unnecessary. 12 It is important that we offer dietary
approaches. They are powerful in their efficacy and advice directed toward ensuring adequacy of nutrition
may lead to healing more often, and are very well and minimisation of symptoms (eg. avoid seeds, skins,
tolerated in the majority of patients. However, their and indigestible fibre when obstructing lesions are
use is associated with mortality (up to 1% in some found; avoid wheat and onions if bloating and diarrhoea
series), mainly from unpredictable, opportunistic are prominent).
infection. This fact alone dampens enthusiasm for Of the micronutrients, iron deficiency is very
their early use unless optimally dosed standard common and relates predominantly to the inability
therapies (eg. azathioprine) have failed. Their cost to absorb iron when chronic inflammation is present.
and lack of subsidy by the Pharmaceutical Benefits Oral iron may be poorly tolerated and ineffective in
Schedule in Australia is also a problem repleting stores.13 There is a swing toward intravenous
• new and promising therapeutic agents are currently iron in such patients as it is safe and well tolerated,
under evaluation and Australian gastroenterologists and successful iron repletion usually leads to improved
and patients are experiencing a new phenomenon in energy levels and quality of life.
IBD – multicentre, international clinical trials.
What has not changed is that surgery remains a key
IBD and colorectal cancer
therapeutic tool to treat specific complications such as The risk of colorectal cancer in patients with IBD
abscess formation, luminal stenosis or poorly controlled involving the colon is increased. Current practices vary
disease. The principle of ‘minimal surgery’, ie. resect as the evidence base for the specifics of a surveillance
the least that is necessary to get the patient over the program is poor. A typical recommendation for a patient
current problem, remains the practice. with ulcerative colitis involving at least the left colon is to

236 3Reprinted from Australian Family Physician Vol. 34, No. 4, April 2005
 Theme: Inflammatory bowel disease

have a second yearly colonoscopy with multiple biopsies Resources

for histopathological assessment for dysplasia after 7–10 Gastroenterological Society of Australia
years of disease.14 Surveillance programs have yet to be www.gesa.org.au
Australian Crohn’s and Colitis Association
introduced in CD, although the risk of cancer of both the
www.acca.net.au
large and small bowel is probably increased. National Association for Colitis and Crohn’s disease (UK)
www.nacc.org.uk
Who should be looking after patients Crohn’s and Colitis Foundation of America
with IBD? www.ccfa.org
Crohn’s and Colitis Foundation of Canada
The most important person looking after the patient www.ccfc.ca
with IBD is the patient themself. The patient needs to Satsangi J, Sutherland LR, editors. Inflammatory bowel
diseases. Edinburgh: Churchill Livingstone, 2003.
be encouraged to take responsibility, to have a good
knowledge of the disease and of the drugs being used, Conflict of interest: Peter Gibson has acted in an
and to be able to work with the attending clinicians. advisory capacity to Schering Plough, Altana, Pfizer,
Of the clinicians, management is best directed by Orphan, and Ferring, and is an investigator in many
someone experienced and knowledgeable about IBD clinical trials of new agents.
(often, but not always a gastroenterologist) and in
whom the patient has confidence and mutual respect.
References
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• If you or your patients are unhappy with the current
status of their IBD, involvement in a clinical trial of a
Email: afp@racgp.org.au AFP
new agent is an option worth considering.

Reprinted from Australian Family Physician Vol. 34, No. 4, April 2005 4 237