Ten top tips
Dr Roger Henderson passes on his insights gained from working
as a GP with a clinical interest in gastroenterology
1 Remember barium enemas are still useful
If a diagnosis of colitis is made by a GP at rigid sigmoidoscopy in the surgery, a barium enema should be ordered even if normal bowel is seen beyond the active disease. Remember – you may be seeing patchy Crohn's disease. If there is any doubt as to the type of disease then colonoscopy is indicated, if only to obtain biopsies.
2 Do not hold on to relapsing patients for too long If you have a patient with known IBD suffering a relapse, and they have not improved on treatment within a fortnight, you should refer them. Fever, anaemia and weight loss are all indicators for referral. Remember that young patients with colitis can deteriorate rapidly to the point of requiring colectomy.
3 Choose 5-ASA preparations carefully The 5-aminosalicylic acid (5-ASA) drugs are the treatment of choice for mild to moderate IBD following initial control with steroids. Using
preparations such as mesalazine and olsalazine
often avoids the major side-effects of sulfasalazine in maintaining remission, such as headache and nausea. Slow-release forms are useful with small-bowel Crohn's disease.
4 Remember antibioitics Localised perianal Crohn's disease often responds well to short courses of metronidazole and/or ciprofloxacin. However, if there is no improvement on such treatment then stronger anti-inflammatory treatment is almost always needed, along with a check sigmoidoscopy to make sure there has been no disease extension.
5 Avoid enteric-coated steroids Because of the rapid transit of acute IBD I do not think enteric-coated steroids should be used since they may not be absorbed properly. In new patients with significant disease it is better to start with an initial high dose of steroids and then reduce fairly quickly rather than try with a low
dose and fail.
6 Do not be afraid to use enemas in distal disease Depending on the disease severity, distal disease may be managed by using prednisolone or mesalazine enemas once or twice a day. In general, drugs delivered as suppositories only reach the rectum up to the sigmoid flexure, those delivered as foam can reach the sigmoid colon, and those delivered as enemas can reach as far as the splenic flexure.
7 All patients need monitoring Ongoing disease requires assessment annually at least. Patients with total colitis should have an annual blood profile and a colonoscopy every two years in my view. Ready access to help should be available at any time between hospital appointments – close liaison with local gastroenterologists and their secretaries can be crucial.
8 Pregnancy carries its own problems Always try to get patients with IBD into remission before they become pregnant. If this is achieved there is good evidence that they are much less likely to relapse during that pregnancy. If possible, try to avoid steroids where possible but mesalazine and sulfasalazine do not appear to cause significant problems if used in pregnancy.
9 Think Crohn's disease in chronic oral ulceration Don't forget that Crohn's may affect any part of the gut from the mouth to the anus. Rarely, patients with Crohn's may present with serious oral ulceration as their initial symptom. Blood tests for inflammatory markers can be a very useful early test in such patients and, if raised, they require full specialist assessment.
10 Take care with adjunctive therapies Adjunctive therapies such as analgesics should also be monitored carefully. Try to use opiates sparingly to reduce the risk of complications such as toxic megacolon developing. I also avoid using NSAIDs because they might increase the production of pro-inflammatory leukotrienes.
Roger Henderson is a GP in Newport, Shropshire
Competing interests None declared