Module description

1 CPD hour

In this learning module, Dr Konstantina Rosiou discusses the more severe cases of IBD encountered in clinical practice. Key topics covered in this module include the predictors of aggressive disease, biological therapy and surgical management, and horizons in the treatment of IBD.

Educational objectives
After taking this activity healthcare professionals should be better able to:

● Identify the factors that will predict a more aggressive disease course
● Be aware of the factors to be considered before initiating advanced therapy
● Appreciate the ongoing research in the area of newer therapeutic approaches for IBD
● Know when to opt for surgical management of the condition

Introduction

Inflammatory bowel diseases (IBD), namely, ulcerative colitis (UC) and Crohn’s disease (CD), are chronic bowel conditions that follow a relapsing and remitting course.

Fortunately, over the past years, the armamentarium of therapeutic agents for the treatment of IBD has expanded, and newer agents are continuously emerging. This article will focus on the management options for severe IBD, including newer and emerging therapies.

Scroll within the image to learn more about the disease course and risk for hospitalisation and colectomy in patients with IBD.

References
1. Fumery M, Singh S, Dulai PS et al. Natural history of adult ulcerative colitis in population-based cohorts: a systematic review. Clin Gastroenterol Hepatol. 2018; 16(3): 343–356.e3.
2. Narula N, Marshall JK, Colombel JF et al. Systematic review and meta-analysis: infliximab or cyclosporine as rescue therapy in patients with severe ulcerative colitis refractory to steroids. Am J Gastroenterol. 2016; 111(4): 477–91.
3. Frolkis AD, Dykeman J, Negrón ME, et al. Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies. Gastroenterology 2013; 145(5): 996–1006.

Predictors of severe disease

The Truelove Witts criteria or the Mayo Clinic score are used to stratify severe UC.

The Harvey-Bradshaw Index can be used to classify disease activity in CD, whereas the Crohn’s Disease Activity Index is used mainly in trials, with scores ranging from 220–450 demonstrating moderate to severe disease.⁴

Scroll within the image below to see the factors that serve as predictors of aggressive disease course for CD and UC.

Crohn's disease
For patients with localised ileocaecal CD, laparoscopic resection can be considered for those failing or relapsing after initial medical therapy, or in those patients preferring surgery to continuation of drug therapy.¹⁰ Surgery is often considered in patients with stricturing or penetrating CD.

A recent study has demonstrated that the rate of surgery for CD has decreased from 10 to 8.8%.¹¹ With the increasing use of biologics, the mortality rate of CD patients after non-selective surgery has declined.

Surgery remains an important treatment approach for patients with IBD

^{(Image credit: Lorenzo Capunata/Moment/Getty Images)}

References
10. Kennedy NA, Jones GR, Lamb CA et al. British Society of Gastroenterology guidance for management of inflammatory bowel disease during the COVID-19 pandemic. Gut 2020; 69(6): 984–90.
11. Lowe SC, Sauk JS, Limketkai BN, Kwaan MR. Declining rates of surgery for inflammatory bowel disease in the era of biologic therapy. J Gastrointest Surg 2021; 25(1): 211–9.
12. Justiniano CF, Aquina CT, Becerra AZ et al. Postoperative mortality after nonelective surgery for inflammatory bowel disease patients in the era of biologics. Ann Surg 2019; 269(4) :686–91.