Inflammatory bowel disease

IBD Patient Advice Line (01896 826454)- This should be the patients first contact for a flare of known IBD. This number can also be contacted by primary care for advice on patient’s not requiring hospital admission.

For non-urgent advice please contact: gastroenterology.nursespecialists@borders.scot.nhs.uk

Crohn’s disease

The treatment of Crohn’s Disease is defined by extent, severity and behaviour. Extent is subdivided into colonic, small bowel or both, with or without perianal or upper GI disease. Severity of inflammation can be difficult to define in Crohn’s Disease: - clinically defined as stool frequency, abdominal pain and wellbeing but symptoms may be a poor indicator of gut inflammation - A commonly used index is Harvey-Bradshaw index (see below)

Number of liquid stools/day	General wellbeing	Abdominal pain	Abdominal mass	Complications (Add 1 point for each)
Score 1 for each	Very well =0	None = 0	None = 0	Arthralgia
	Slightly below par = 1	Mild = 1	Definite = 1	Uveitis
	Poor = 2	Moderate = 2	Dubious = 2	Erythema nodosum
	Very poor = 3	Severe = 3	Definite & tender = 3	Aphthous ulcers
	Terrible = 4			Pyoderma gangrenosum
				Anal fissure
				New fistula
				Abscess

Score interpretation: <5 = remission, 5-7 = Mild disease, 8-16 = Moderate disease, >16 = Severe disease

Ulcerative colitis

The severity of disease in ulcerative colitis determines the management.

	Bloody stools per day	Systemic disturbance (Fever, HR >90, Hb <105, CRP >30
Mild	<4	No
Moderate	4-5	No
Severe	>5	Yes

Who to refer, who not to refer, how to refer

Who to refer:

Patients who are believed to be having a flare of IBD can be discussed with GI nurse specialists if advice is needed.

Patients with severe symptoms should be admitted to hospital.

Patients who are new to the area with known IBD but who are not experiencing a flare can be routinely referred to gastroenterology via SCI gateway.

Who not to refer:

Patients with IBD who are felt to have other pathology unrelated to their IBD.

How to refer:

Patients who require admission to hospital should be discussed with the medical registrar on call.

Primary care management

All patients with a suspected flare of IBD should have:

Stool cultures- including C.Diff (and OCP if travel history)
Blood tests- FBC, U&E, LFT, Calcium/albumin, CRP
Faecal calprotectin

Crohn’s disease

Management is based on the degree of disease and the location of the patient’s disease:

Colonic Crohn’s disease	Mild	Moderate	Severe
	Consider giving no treatment If faecal testing is normal, consider concurrent IBS Repeat faecal testing at 3 months	Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg/week to 0 Budesonide 9 mg od for 6 weeks is an alternative for Prednisolone intolerant patients with inflammation in right and transverse colon Engage local IBD Service at early stage	Admit to hospital
Ileo-colonic crohn’s disease	Consider giving no treatment If faecal testing is normal, consider concurrent IBS If previous ileal resection consider bile salt malabsorption and give Cholestryamine 4 g bd. Repeat faecal testing at 3 months	Budesonide 9 mg od for 6 weeks then 6 mg od for 1 week, then 3 mg od for 1 week, then stop. If no response, Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg per week to 0. Polymeric diet is an alternative to steroids. Engage local IBD Service at early stage	Admit to hospital
Extensive small bowel disease	Mild disease	Moderate disease	Severe disease
	Low residue diet. Consider giving no treatment. If faecal testing is normal, consider concurrent IBS Repeat faecal testing at 3 months Engage local IBD Service for advice at early stage	Polymeric diet: discuss with secondary care and refer to dietitian. Budesonide 9 mg od for 6 weeks, then 6 mg od for 1 week, then 3 mg od for 1 week, then stop. If no response, Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg per week to 0. Polymeric diet is an alternative to steroids. Engage local IBD Service at early stage	Admit to hospital
Perianal disease	Mild	Moderate	Severe
	Assess temperature, inspect perineum and do rectal examination. Is there any sepsis present? As a general rule, if the patient is unable to sit properly they should be referred	Give Metronidazole or Ciprofloxacin for 14 days in the first instance Most patients will need a MRI or an EUA – engage with local IBD Service at an early stage	Admit to hospital

Ulcerative colitits

Management is based on severity

Proctitis	Mild/moderate		Severe
	Salofalk suppositories 1 g nocte, steroid suppository if mesalazine intolerant If no response after 2 weeks, add oral Salofalk 1.5 - 3g/day If deterioration, consider Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg per week to 0 Engage with local IBD Service at early stage		Admit to hospital
Left sided colitis	Mild	Moderate	Severe
	Give oral Salofalk 1.5-3g /day OR Salofalk liquid enema 2 g nocte, steroid enema if mesalazine intolerant If no response, give both oral Salofalk and Salofalk liquid enema If still no response, add Prednisolone 40 mg od for 2 weeks, then reduce dose by 5 mg per week to 0 Engage with local IBD Service at early stage	Give oral Salofalk 1.5-3g /day AND Salofalk liquid enema 2 g nocte If no response, add Prednisolone 40 mg od for 2 weeks, then reduce dose by 5 mg per week to 0 Engage with local IBD Service at early stage	Admit to hospital
Extensive/Pan colitis	Mild/moderate		Severe
	Give Mesalazine Salofalk 1.5-3g /day If no response, add Prednisolone 40 mg od for 2 weeks, then reduce by 5 mg per week to 0. Engage with local IBD Service at early stage		Admit to hospital

Resources and links

Patient/Practitioner Advice Line (01896 826454)
COVID vaccination in IBD
NICE | The National Institute for Health and Care Excellence
Crohn's & Colitis UK (crohnsandcolitis.org.uk)

Local service contact details