Although inflammatory bowel disease is mainly managed in secondary care, the revised BSG guideline contains much useful information for GPs, says Dr Mark Cottrill
- Active left sided or extensive ulcerative colitis should be treated with oral aminosalicylates or corticosteroids to give prompt relief of symptoms. The different options should be discussed with the patient and the views of the patient taken into account.
- Active distal colitis should be treated with topical mesalazine or topical steroid combined with oral mesalazine or corticosteroids to give prompt relief of symptoms.
- Severe ulcerative colitis should be managed jointly by a gastroenterologist and a colorectal surgeon. Patients should be kept informed of treatment and prognosis, including a 25-30% chance of needing colectomy.
- Patients with ulcerative colitis should normally receive maintenance therapy with aminosalicylates, azathioprine, or mercaptopurine to reduce the risk of relapse.
- Initial treatment of active ileal or ileocolonic Crohn’s disease with high dose mesalazine, corticosteroids, nutritional therapy, or surgery should be tailored to the severity of the disease. The views of the patient should be taken into account.
- Metronidazole 400mg tds and/or ciprofloxacin 500mg bd are appropriate first-line treatments for simple perianal fistulae.
- For the maintenance of remission, smoking cessation is probably the most important factor.
- Immunomodulation with azathioprine, mercaptopurine or methotrexate is usually appropriate if patients relapse more than once a year as steroids are withdrawn. Treatment with these agents should be tried if steroids cannot be withdrawn without deterioration in disease activity.
Nearly a quarter of a million people are affected by inflammatory bowel disease (IBD) in the UK. The prevalence of ulcerative colitis is reported as being 100-200 sufferers per 100 000, and that of Crohn’s disease as 50-100 per 100 000 – both are likely to be underestimates.1
The incidence of ulcerative colitis appears to be stable but Crohn’s disease may be on the increase, although it is unclear why. Both affect young people, with incidence peaking between the ages of 10 and 40 years.1
The management of IBD is mostly confined to secondary care, but GPs are actively involved in supporting patients in the community. Patients with IBD do not like seeing different doctors in clinic, and GPs can provide continuity of care. GPs are also well placed to attend to the physical and emotional aspects of the disease and to problems, for example relating to employment. The recent update to the British Society of Gastroenterology’s 1996 guideline is therefore very welcome.1
The introduction to the new guideline promises an evidence-based document for "clinicians and allied professionals” caring for patients with IBD in the UK. Although at first glance the information seems to be devised by specialists for specialists, a more detailed examination of the text reveals a number of recommendations relevant to general practice and the document could be an invaluable reference source.
The guideline was developed from a comprehensive literature search and the recommendations are graded according to the category of supporting evidence (Table 1, below).
|Table 1: Grading of recommendations|
Impact of the disease
The authors acknowledge the problems patients with IBD may experience, both physical and psychological. In an unusual step they have included the views of the National Association for Colitis and Crohn’s Disease, putting forward the patient’s perspective and expectations.
GPs will recognise the emotional upset that a diagnosis of IBD brings, with symptoms that are often embarrassing and distressing. There are many points made that will be relevant to consultations in the surgery both at the initial diagnosis and in continuing care.
Diagnosis and investigation
The guideline provides a short but comprehensive overview of IBD, including its epidemiology, theories of pathogenesis and the clinical features and pattern of the disease. In this section the authors deal with the diagnosis and investigation, from the detailed history of the complaint at presentation to hospital based investigations such as endoscopy.
Taking a full history should include asking about any recent travel, medication, smoking status and family history. Details about stool frequency and consistency, urgency, rectal bleeding, abdominal pain, malaise, fever, weight loss and symptoms of extraintestinal (joint, cutaneous, eye) manifestations of IBD should be recorded.
General examination should incude wellbeing, pulse rate, blood pressure, temperature, checking for anaemia, fluid depletion, weight loss, abdominal tenderness or distension, palpable masses and perineal examination.
Recommended initial tests include full blood count, urea and electrolytes, erythrocyte sedimentation rate or C-reactive protein, liver function tests, and microbiological testing for infectious diarrhoea. Such tests can be performed in general practice prior to endoscopy and biopsy in hospital.
The authors acknowledge that drug treatment for IBD is evolving rapidly, and the guideline provides a summary of the principal drug treatments. The list of drug options – aminosalicylates, corticosteroids, thiopurines, methotrexate, ciclosporin and infliximab – includes details of their efficacy, evidence for use, dosage and delivery, and side-effects, as well as guidance for monitoring therapy where relevant. GPs will find this section a valuable source of reference when managing IBD patients on therapy.
The recommendations for medical management of IBD are divided into ulcerative colitis (and subdivided as to the site and activity) and Crohn’s disease. Many of the therapeutic decisions are of more relevance to secondary care; however, some of the recommendations will be of interest to GPs (Box 1, below).
The guideline emphasises that stopping smoking is probably the most important factor in maintaining remission in patients with Crohn’s disease. Patients should be given advice and support to help them quit. GPs are well placed to help patients give up smoking, whether by referral to a smoking cessation counsellor or to the practice nurse to provide the follow-up, support and prescribe anti-smoking medication.
Associated aspects of IBD
The final section of the guideline refers to associated aspects of IBD. This section covers a number of situations that may be very relevant to primary care management.
Abdominal pain in IBD is under-researched and there may be many mechanisms involved. Associated irritable bowel syndrome may co-exist and other intra-abdominal causes of pain should be considered. These should be treated if possible. For non-specific pain relief the use of an opiate that has less effect on motility, such as tramadol, is suggested.
Specialists continue to debate the value of surveillance colonoscopy for colon cancer and the recommendations are all grade C. The guideline advises that the appropriateness of surveillance should be discussed with the patient and a joint decision made based on the balance of benefit.
A colonoscopy is recommended after 8-10 years for all those with ulcerative colitis, in order to reassess the extent of the disease. For those with extensive colitis who wish to be screened for colorectal cancer, this should be repeated every three years in the following decade, every two years in the decade after that and annually thereafter.
The guideline provides useful recommendations regarding management in pregnancy, and short discussions about nutrition, management of extra-intestinal manifestations of IBD and the risk of osteoporosis.
IBD specialist nurses have an increasingly important part to play in managing the disease. Both patients and professionals appreciate their input, and they are cost-effective. Their role varies, but may include liaising between patients, GPs and other members of the multi-disciplinary team, supporting patients, and providing services such as helplines and specialist IBD clinics.
The guideline concludes with a list of sources of information which medical staff can recommend to patients. Patients generally find such resources useful, especially when health professionals are willing to help them interpret the material if necessary.
This guideline is a very useful source of information for GPs wishing to update their understanding of the diagnosis and management of IBD.
- Carter MJ, Lobo AJ, Travis SPL on behalf of the IBD Section of the British Society of Gastroenterology. Guidelines for the management of inflammatory bowel disease in adults. Gut 2004; 53(Suppl V): v1-v16.