People generally first come to see Dr Wilson when their disease is in the ‘flare-up’ stage, so treatment usually begins with medication to get things under control and to reduce the current inflammation.
Once this has been achieved and the disease is in remission, treatment will focus on maintaining this remission and preventing new flare-ups as much as possible.
Initial treatment for IBD
Initial treatment aims to reduce the inflammation. There are several ways to do this and they are used in order of severity of side-effects. The least troublesome drugs are used first and others only introduced if these are unsuccessful.
The usual order of treatments recommended by Dr Wilson is:
- Aminosalicylates – such as mesalazine, which reduce inflammation.
- Corticosteroids – such as prednisolone, which are stronger anti-inflammatories for cases where aminosalicylates have not worked.
These drugs may be given orally, or as a suppository or enema, depending on the location of the disease within the digestive tract.
In severe cases of IBD, or where a patient has had not had an adequate response to first-line treatments, biological treatments, such as infliximab can be used. Biological treatments change the way the immune system reacts, reducing its capacity to harm its own tissues. However, care is needed as biological treatments are systemic (they travel around the body in the blood) and so will reduce your immune response throughout your body, leaving you more vulnerable to other diseases and infections.
Maintenance treatment for IBD
Once the disease has been brought under control, the aim of the treatment switches to keeping the symptoms in remission and avoiding further flare-ups.
This is achieved by reducing the doses of the above drugs, in particular aminosalicylates to a regular, maintenance level. If flare-ups do still occur, they can often be controlled by adding in a regular dose of immunosuppressant, such as azathioprine and mercaptopurine, which subdue the immune response and reduce the risks from long term steroid use.
Long term, regular use of steroids is not recommended, as this can have serious side effects and even slow down the healing process that is essential to maintaining remission.
Surgical options for inflammatory bowel disease
In severe cases of IBD, surgery is the only option to prevent life-threatening complication such as toxic megacolon, perforations and blockages of the bowel.
Surgery may also be considered as an option in cases where repeated flare-ups are seriously affecting quality of life and where the patient has simply had enough of dealing with exhausting symptoms, such as constant diarrhoea and fatigue, and the side effects of the various drugs.
Surgical options in ulcerative colitis
Surgery for ulcerative colitis normally involves the removal of the whole of the large intestine, called a total colectomy. This may at first appear to be an extreme solution, but it does cure the disease, while also dealing with the increased risk of bowel cancer.
In the past, a colectomy meant having to wear a stoma bag on the outside of your body, however modern surgical techniques mean that these days you are more likely to be offered an internal ileo-anal pouch, which allows you to store and pass stools relatively normally.
Surgical options in Crohn’s disease
Surgery for Crohn’s disease does not cure it and the disease will almost always reoccur, often close to the original inflammation site. However, many patients report dramatic improvements in their symptoms straight away following surgery, allowing them to return to a normal life.
When a section of the bowel is removed due to Crohn’s disease, a temporary stoma is often created on the outside of the abdomen to allow the healthy ends of the excision to rest and recover. This stoma is then reversed after a few months and normal bowel function is re-established.
Occasionally it may be necessary to rest the large intestine if Crohn’s disease is severe and not responding to medical treatments. This is done by diverting the small intestine to a stoma on the skin in an operation called a loop ileostomy. This can often be performed using keyhole surgery techniques.