Inflammatory bowel disease affects many parts of the gut in many different ways, making treatment difficult and complex.

In the past few years increasing understanding of the condition and new research has led to much more effective forms of treatment, individualised for each manifestation.

Treating ulcerative colitis

  • Proctitis and proctosigmoiditis — in this form where it is mainly the lower part of the bowel which is affected, established treatment includes oral sulphasalazine (5-ASA linked to sulphapyridine as a carrier) and either steroid enema or foam preparations for mild to moderate exacerbations and short courses of oral steroids (prednisolone) for persistent symptoms. 5-ASA in the carrier sulphapyridine used to be associated with side effects of headache, nausea and vomiting, as a result of the carrier. Some of the newer preparations have eliminated or reduced the dose of the carrier which has got rid of some of the side effects. However, they may have side effects of their own, such as diarrhoea, and are a lot more expensive than the original compound. Their main use is in those who are intolerant of sulphasalazine and in men planning a family since sulphasalazine tends to decrease sperm motility. Foam forms of 5-ASA are expensive and no better then their steroid equivalents.

  • Acute colitis — affecting the gut higher up, this form of ulcerative colitis is often treated with short courses of oral steroids for exacerbations. In patients with severe disease including weight loss, fever, inability to eat and cardiac problems, then intravenous fluids, intravenous steroids and sometimes blood transfusion is used. If there is no response within a few days, those with disease this severe are advised to have surgical treatment. About 50 percent of people will respond to intravenous cyclosporin, but they need continuing treatment with oral cyclosporin, relapse rates are high and there are many side effects.

  • Persistent symptoms — these are sometimes treated with azothioprine in disease affecting both the upper and lower gut. However, this has many side effects and is only used in severe and persistent symptoms in spite of good compliance on other treatment.

    Treating Crohn's disease

  • Distal ileal disease — this is the most common form of Crohn's disease. It generally leads to what are called strictures in which the inflammation of the bowel causes contraction and narrowing in particular areas. This will lead to intestinal obstruction. These episodes can be treated by keeping the patient off all oral food and fluid, maintaining with intravenous fluids. If there are many episodes of obstruction then the offending part of the bowel is surgically removed.

    Some of the newer steroids such as budesonide are used in these cases, in preparations which allow controlled release in the part of the bowel which is actually affected. Budesonide is not absorbed in the same way as prednisolone, so does not lead to the same incidence of steroid induced side effects.

    Sulphasalazine and 5-ASA are of little use as maintenance therapy in Crohn's disease.

  • Crohn's disease of the colon — this is far more difficult to treat than ulcerative colitis (affecting the same region of the bowel). A short course of oral sulphasalazine and steroid enemas is often effective. In persistent cases short courses of oral prednisolone are used. Immunosuppressive therapy may be used in severe persistent disease.

  • Extensive Crohn's disease of the colon — in acute cases oral prednisolone is useful. Unfortunately there is little evidence that sulphasalazine or 5-ASA is useful as it is in ulcerative colitis. However, there is good evidence that azothioprine helps to relieve chronic, severe, persistent symptoms, although it is slow to take effect, and may only be useful for four to five years. This drug should be stopped if upper abdominal pain and vomiting occurs, and bone marrow suppression can be a problem.

  • Crohn's disease affecting the anal region — although unsightly, is usually not a cause of symptoms. If infection occurs then pressure from pus building up may cause problems, and then surgical drainage is used.

  • Medical versus surgical treatment — surgical treatment is generally regarded as a last resort when medical treatment has failed, but is actually an integral part of management, particularly in the face of the long-term risk of cancer developing. The problem with surgery is that some patients require a permanent stoma and disease may recur.

  • Smoking and Crohn's disease — there is now plenty of evidence that smoking adversely effects outcome in patients with Crohn's disease, a further reason to stop smoking!

    Pregnancy and inflammatory bowel disease

    It is a good idea to try and conceive while in remission since this produces the best outcome for both baby and the underlying disease in the mother.

    Although it is obviously better to take no medication during pregnancy there is no evidence that sulphasalazine, 5-ASA or corticosteroids are associated with an increased risk of fetal abnormality. This is not the case for azothioprine, which should be avoided in pregnancy, although pregnant women taking immunosuppressive drugs after organ transplant have not experienced an increase in fetal abnormality rate.


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