Inflammatory Bowel Disease
Advanced Nursing Guide

1. Induction: Corticosteroids (prednisolone/budesonide) for active flares. Exclusive enteral nutrition (EEN) preferred in paediatric Crohn's. IV steroids for severe disease.
2. Maintenance: Azathioprine/6-MP (first-line immunomodulator). Methotrexate (15–25mg SC/IM weekly) — alternative if thiopurine intolerance/failure; teratogenic — reliable contraception mandatory.
3. Biologics (earlier in Crohn's): Anti-TNF (infliximab/adalimumab) — earlier use recommended in high-risk Crohn's (penetrating/fistulising disease, perianal involvement, extensive disease, prior surgery).
4. Vedolizumab / Ustekinumab: Second-line biologics — particularly after anti-TNF failure or contraindication. Ustekinumab preferred in Crohn's with concomitant psoriasis/psoriatic arthritis.
5. Surgery: Ileocaecal resection for isolated terminal ileal disease — potentially better outcomes than medical therapy in selected patients. Strictureplasty for strictures. Drainage for abscesses.

1. IV Hydrocortisone 100mg QDS (400mg/day) — first-line therapy. Equivalent to prednisolone 75mg. Continue for 5 days, then assess response.
2. IV Fluid Resuscitation + Electrolyte Replacement — maintain K⁺ ≥4.0 mmol/L (hypokalaemia worsens colonic motility). Replace Mg²⁺ if low.
3. Nil by Mouth Assessment — consider if surgical intervention anticipated or toxic megacolon suspected.
4. VTE Prophylaxis (LMWH) — IBD = hypercoagulable state (elevated clotting factors, platelet activation). LMWH should be prescribed in ALL hospitalised IBD patients. Risk of VTE is 3-fold higher in IBD vs general population.
5. Nutritional Support — dietitian review. Enteral nutrition preferred if gut functional. Parenteral nutrition if surgery anticipated or severe malnutrition.
6. Stool cultures — exclude C. difficile (particularly if recent antibiotics) and CMV (check CMV PCR in tissue — reactivation can complicate ASUC, especially on immunosuppression).
7. IV Antibiotics — if toxic megacolon suspected, perforation risk, or evidence of sepsis. Not routine for all ASUC.
8. Surgical review within 24 hours — joint medical-surgical team care from admission.
9. Daily stool charts — document frequency, consistency (Bristol Stool Chart), blood content, timing.
10. Daily bloods — FBC, U&E, CRP, albumin, Mg²⁺, phosphate, LFTs.

1. Subtotal colectomy + end ileostomy — operation of choice in acute setting. Preserves rectum for future pouch formation. Safer in acutely unwell, malnourished or immunocompromised patient.
2. Elective ileal pouch-anal anastomosis (IPAA — "J-pouch") — staged procedure once patient recovered and off immunosuppression. Restores intestinal continuity without a permanent stoma.
3. Total proctocolectomy + permanent ileostomy — option if pouch not suitable (poor sphincter function, elderly, perianal disease in indeterminate colitis).

Malnutrition affects up to 75% of hospitalised IBD patients and 25–30% of outpatients. Causes include reduced intake (anorexia, pain, food fear), malabsorption, and increased metabolic demands during active disease. Use MUST (Malnutrition Universal Screening Tool) on admission and at each review.

1. Confirm indication: Hb <100 g/L with iron deficiency (low ferritin/transferrin saturation), or oral iron intolerance/failure in active IBD.
2. Calculate iron deficit using Ganzoni formula or use simplified dosing by weight and Hb level.
3. Maximum single dose: 1000mg (or 20mg/kg). Can repeat if iron stores not replete.
4. Administer by IV infusion over 15–30 minutes (diluted in 100–250mL 0.9% NaCl).
5. Monitor for infusion reactions: flushing, hypotension, rash. Have resuscitation equipment available. ANAPHYLAXIS rare but possible.
6. Recheck ferritin + Hb at 4–8 weeks post-infusion to assess response.

IBD significantly increases CRC risk, particularly with longer disease duration and greater colonic extent. Risk increases after 8–10 years of extensive UC or colonic Crohn's disease.

1. Plan conception during remission — active IBD at conception associated with preterm birth, low birth weight, and disease flare in pregnancy.
2. Most IBD medications are safe in pregnancy: 5-ASA, corticosteroids (1st trimester caution), azathioprine (safe — do not stop), anti-TNF (safe until 3rd trimester; discuss risks vs benefits of continuing into 3rd trimester).
3. Methotrexate is CONTRAINDICATED in pregnancy and breastfeeding — highly teratogenic. Discontinue ≥3 months before conception in both males and females.
4. Vedolizumab: limited data — discuss individually. Ustekinumab: limited data — specialist decision.
5. Joint IBD/obstetric care pathway. Increased monitoring in 3rd trimester. Mode of delivery: vaginal delivery preferred unless perianal/active disease or obstetric indication for CS.

1. Pre-infusion: confirm pre-treatment screening complete (TB/HBV/HIV), check drug trough levels if applicable, review vital signs, weight (dose is weight-based).
2. Reconstitute infliximab in 250mL 0.9% NaCl. Use in-line filter (1.2 micron). Administer over 2 hours (100mg/hour minimum; may accelerate to 1 hour in established patients per protocol).
3. Pre-medication: paracetamol 1g PO + antihistamine (chlorphenamine 10mg IV or loratadine 10mg PO) to reduce infusion reaction risk — per local protocol.
4. Monitoring during infusion: BP, HR, temperature every 30 minutes. Have resuscitation equipment and adrenaline immediately available for anaphylaxis management.
5. Infusion reactions: Mild (flushing, urticaria, fever, pruritus) — slow/stop infusion, antihistamine/hydrocortisone, restart when settled. Severe (bronchospasm, hypotension, anaphylaxis) — STOP immediately, adrenaline 0.5mg IM, call emergency team.
6. Post-infusion: observe 30–60 minutes. Document infusion, any reactions, and next scheduled date. Provide patient with infusion record card.

1. Demonstrate injection technique using training device. Patient to observe then perform supervised injection.
2. Rotation of injection sites: abdomen (not periumbilical), anterolateral thigh, upper outer arm. Avoid bruised, tender, red, or scarred skin.
3. Sharps disposal education: sharps bin, do not recap needles, local authority collection arrangements.
4. Storage: refrigerate 2–8°C. Remove from refrigerator 30 minutes before injection to reduce discomfort. Do not freeze. Can be stored at room temperature ≤25°C for up to 14 days for adalimumab.
5. Missed dose: advise patient to contact IBD helpline for guidance rather than double-dosing.
6. Document injection education in patient records. Provide written patient information.

Anxiety and depression prevalence in IBD is 2–3 times higher than the general population. IBD-specific psychosocial stressors include unpredictable symptoms, disease uncertainty, body image concerns (stoma, weight changes), treatment burden, and impact on employment and relationships.

IBD was previously rare in the Arabian Gulf region but incidence has been rising significantly over the past two decades, mirroring patterns seen in other newly industrialised nations. This epidemiological shift is attributed to rapid urbanisation, adoption of Western dietary patterns (reduced fibre, increased processed food/fat), changes in gut microbiome, and the hygiene hypothesis (reduced early-life microbial exposure with improved sanitation).

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