IBD Overview: Inflammatory Bowel Disease is a group of chronic, relapsing-remitting, immune-mediated gastrointestinal conditions. The two main forms are Ulcerative Colitis (UC) and Crohn's Disease (CD). Pathogenesis involves dysregulated mucosal immune response to gut microbiota in genetically susceptible individuals.
UC causes continuous mucosal inflammation beginning at the rectum and extending proximally in a contiguous fashion. Inflammation is limited to the mucosa and submucosa — never transmural.
CD is characterised by transmural inflammation that can affect any part of the GI tract from mouth to perianal region. Classic feature: skip lesions — areas of disease separated by normal bowel.
| Feature | Ulcerative Colitis | Crohn's Disease |
|---|---|---|
| Location | Colon & rectum only | Any GI tract (mouth to anus) |
| Distribution | Continuous from rectum | Skip lesions — discontinuous |
| Depth of inflammation | Mucosal/submucosal only | Transmural (full thickness) |
| Rectal involvement | Always (95%) | Variable (50% spared) |
| Bloody stool | Yes — hallmark | Variable; less prominent |
| Perianal disease | Rare | Common — fistulae, abscesses |
| Fistulae | Rare | Common (B3 behaviour) |
| Strictures | Rare (suspect cancer) | Common (B2 behaviour) |
| Granulomas (histology) | Absent | Present in 30–60% (pathognomonic) |
| Small bowel involvement | No (except backwash ileitis) | Yes — especially terminal ileum |
| PSC association | Strong (UC >> CD) | Rare |
| Curative surgery | Yes — proctocolectomy curative | No — recurrence after resection |
| Preferred biologic first-line | Anti-TNF or vedolizumab | Anti-TNF; ustekinumab |
Scores 8 variables over 7 days including stool frequency, abdominal pain, general wellbeing, extra-intestinal manifestations, antidiarrhoeal use, abdominal mass, haematocrit, body weight.
Scores stool frequency, rectal bleeding, mucosal appearance on endoscopy, physician global assessment (0–3 each). Total 0–12.
Partial Mayo (without endoscopy, 0–9) used for clinical monitoring. Faecal calprotectin correlates well with mucosal activity.
Simplified Crohn's index: general wellbeing (0–4), abdominal pain (0–3), number of liquid stools/day, abdominal mass (0–3), complications (1 point each).
Peripheral arthropathy (parallels bowel activity) and axial arthropathy (ankylosing spondylitis — independent of bowel activity). Affects 10–20% of IBD patients.
Episcleritis — correlates with bowel activity; painless redness. Uveitis — sight-threatening; independent of bowel activity; urgent ophthalmology referral.
Erythema nodosum — tender red nodules on shins, correlates with activity. Pyoderma gangrenosum — painful ulcerating lesion; requires immunosuppression (not debridement).
PSC is strongly associated with UC (70–80% of PSC patients have UC). Causes progressive biliary fibrosis. Monitor with LFTs, ALP. PSC + IBD = highest CRC risk — annual colonoscopy.
IBD was historically rare in the Arab world. Rates are now rising dramatically across GCC countries, particularly in younger populations. Attributed to rapid Westernisation — dietary change, urbanisation, reduced microbial diversity, antibiotic overuse.
Ramadan fasting: patients often worry about medication adherence. Rectal preparations (suppositories/enemas) are generally considered permissible. Oral medications can usually be adjusted to pre-dawn and post-Iftar dosing — discuss with gastroenterologist.
Dietary triggers: spicy foods, high refined sugar intake, low dietary fibre — common in GCC dietary patterns.
Biologic access has expanded significantly in GCC. Saudi Arabia, UAE, Qatar, Kuwait now have national formularies including anti-TNF agents, vedolizumab, ustekinumab. DHA (Dubai), MOH Saudi Arabia, and Qatar formularies list first-line biologics. Cost remains a barrier for some expatriates without insurance coverage.
Faecal calprotectin is the key non-invasive discriminator. Values 50–200 mcg/g are borderline — repeat or proceed to colonoscopy based on clinical suspicion.
Acute Severe Ulcerative Colitis (ASUC) is a medical emergency with significant mortality if managed suboptimally. Requires urgent hospital admission, IV steroids, daily senior review, and early surgical consultation.
Acute severe UC is defined as 6 or more bloody stools per day PLUS at least one of the following systemic features:
| Parameter | Mild | Moderate | Acute Severe |
|---|---|---|---|
| Stool frequency | <4/day | 4–6/day | ≥6/day with blood |
| Pulse rate | Normal | <90 bpm | >90 bpm (tachycardia) |
| Temperature | Afebrile | ≤37.8°C | >37.8°C (fever) |
| Haemoglobin | Normal | >105 g/L | <105 g/L (anaemia) |
| ESR | Normal | <30 mm/hr | >30 mm/hr |
| CRP | Normal | Mildly raised | >30 mg/L |
Exam Tip: Truelove & Witts (1954) remains the gold standard ASUC definition. The classic exam question: "6 bloody stools + pulse >90 OR temp >37.8 OR Hb <105 OR ESR >30." One systemic feature is sufficient alongside ≥6 bloody stools.
Reassess at day 3 of IV steroids using the Oxford (Travis) criteria to predict likelihood of requiring colectomy:
Stool frequency >8/day OR (stool frequency 3–8/day + CRP >45 mg/L) on day 3 = 85% chance of colectomy during that admission.
Continue IV steroids to day 5–7, then consider conversion to oral prednisolone; plan discharge with step-down
Rescue therapy discussion: infliximab 10mg/kg or ciclosporin 2mg/kg/day IV — or proceed to colectomy
Toxic megacolon is a life-threatening complication of severe colitis. Defined as total or segmental non-obstructive colonic dilatation >6cm on plain AXR, with systemic toxicity.
Emergency colectomy if: peritonitis, perforation, rapid clinical deterioration, or no improvement within 24–72h of maximal medical therapy.
Malnutrition is common in ASUC due to disease activity, reduced intake, and increased catabolism. Dietitian referral on day 1 is mandatory.
Accurate stool documentation is the most important nursing observation in ASUC. Clinical decisions (rescue therapy, colectomy) depend on stool frequency data.
24-hour stool count reviewed each morning round. Senior clinician uses this data for Oxford criteria assessment at day 3.
First-line therapy for mild-to-moderate UC. Acts topically on colonic mucosa — reduces mucosal inflammation via inhibition of prostaglandin and leukotriene synthesis.
Nurse tip: Non-adherence is the leading cause of UC relapse. Check compliance at every clinic review. Rectal preparations are often abandoned — address barriers proactively.
Used for induction of remission only — not for maintenance. Long-term steroid use causes significant harm: osteoporosis, adrenal suppression, diabetes, cataracts, avascular necrosis.
Controlled-ileal-release formulation — acts locally in terminal ileum and right colon. First-pass hepatic metabolism limits systemic side effects. Used for mild-moderate ileocaecal Crohn's. Dose: 9mg OD for 8 weeks, then taper.
Systemic steroids for moderate-severe UC/CD flares. Prednisolone 40mg OD orally for 4 weeks, then taper by 5mg/week. IV methylprednisolone 60mg/day or hydrocortisone 100mg QDS for ASUC. Monitor glucose, BP, electrolytes. PPI cover for GI protection.
Steroid dependency: Relapse within 3 months of stopping steroids OR requiring >10mg prednisolone/day = immunosuppressant or biologic indication.
Thiopurine methyltransferase (TPMT) enzyme metabolises thiopurines. Low/absent TPMT = severe myelosuppression risk. Check TPMT genotype or phenotype before initiating.
Vedolizumab has gut-selective mechanism (blocks gut lymphocyte homing) — favourable systemic safety profile; lower infection risk than anti-TNF. Preferred in elderly, infection-prone, or those with previous malignancy.
JAK inhibitors are oral — convenient but carry VTE, herpes zoster, and cardiovascular risk (boxed warning). Screen appropriately before initiating.
Calprotectin is a protein released by neutrophils. Elevated in intestinal inflammation — correlates with mucosal disease activity. Non-invasive stool test; patient-collected at home.
| Procedure | Used in | Description | Nursing Considerations |
|---|---|---|---|
| Proctocolectomy + IPAA (J-pouch) | UC (preferred) | Remove colon & rectum; ileum fashioned into reservoir anastomosed to anus. Continence preserved. | Pouchitis risk; pouch function education; 4–8 stools/day is normal |
| Proctocolectomy + Permanent Ileostomy | UC (if IPAA not suitable) | Remove entire colon & rectum; end ileostomy formed. No residual disease risk. | Stoma bag management; high output monitoring; dehydration risk |
| Subtotal Colectomy + Ileostomy | UC (emergency) / CD | Emergency colectomy leaving rectal stump. Second stage later (completion proctectomy or IPAA). | Two-stage procedure; stoma is temporary |
| Segmental Resection | Crohn's | Resection of diseased segment (e.g., ileocaecal). Conservative to preserve bowel length. | Risk of re-operation; post-op Crohn's recurrence monitoring |
| Strictureplasty | Crohn's (stricture) | Widening of stricture without bowel resection. Bowel-preserving. | Used when multiple strictures; avoids short bowel syndrome |
Crohn's vs UC surgery: IPAA (J-pouch) is avoided in Crohn's due to high risk of pouch failure from recurrent Crohn's in the pouch. Patients with Crohn's usually receive permanent ileostomy. UC surgery can be curative.
The stoma nurse specialist marks the optimal stoma site pre-operatively. This is one of the most important pre-operative nursing interventions — poor siting leads to leakage, skin problems, and reduced quality of life.
Normal ileostomy output: 500–1,500mL/day. High output (>2,000mL/day) requires active management — dehydration and electrolyte loss are major risks.
Pouchitis is the most common complication after IPAA (J-pouch), occurring in up to 50% of UC patients within 10 years. Caused by dysbiosis in the pouch reservoir.
Nurse-led pouch clinic: stool frequency diary, endoscopic assessment with PDAI scoring, patient helpline access.
Perianal Crohn's (fistulae, abscesses, skin tags) causes significant morbidity and quality of life impairment. Nurse-specialist management is essential.
A non-cutting seton (loose silk thread passed through fistula tract) is used to control complex perianal fistulae, allow drainage, and prevent abscess. Setons may remain in place for months.
Infliximab (anti-TNF) is first-line medical therapy for complex perianal fistulae in Crohn's. Fistula closure rate ~50% at 1 year. Nurse coordinates pre-biologic screening and infusion scheduling.
There is no single universal IBD diet. Dietary management is highly individual. Key principle: identify personal trigger foods, especially during flares.
Most oral IBD medications can be timed to pre-Suhoor (dawn) and post-Iftar (sunset) doses. This allows continuous treatment whilst maintaining the fast. Discuss medication timing plan with gastroenterologist 4–6 weeks before Ramadan.
Islamic scholars generally agree that rectal suppositories and enemas do not invalidate the fast as they are not nutritive. However, patients may feel uncertain — respectfully explore concerns and involve imam consultation if helpful for the patient.
Prolonged fasting, dietary changes at Iftar (high sugar, fried foods), disrupted sleep, and missed doses all increase flare risk. Active disease = acceptable exemption from fasting (Islamic law). Provide written Ramadan IBD action plan to all IBD patients pre-Ramadan.
Most biologics are recombinant proteins (not porcine or bovine derived). Infliximab, adalimumab, vedolizumab, and ustekinumab are generally considered halal. Some may contain trace excipients — pharmacy/religious scholar consultation available if patient requests formal verification. Do not delay treatment — reassure patients that life-saving medications are permissible under Islamic medical ethics (maslaha).
IBD patients, particularly extensive UC, have an elevated colorectal cancer (CRC) risk compared to the general population. Risk increases with disease duration, extent, and severity of inflammation.
IBD nurse specialist coordinates surveillance scheduling, patient recall system, and bowel prep education for colonoscopy.
Osteoporosis risk is significantly elevated in IBD due to:
Anxiety and depression affect up to 30–40% of IBD patients — significantly higher than the general population. Mental health impacts medication adherence, healthcare utilisation, and quality of life.
| Feature | UC — Remember | CD — Remember |
|---|---|---|
| Classic presentation | Bloody diarrhoea + tenesmus | RIF pain + weight loss + non-bloody diarrhoea |
| Location rule | Colon only, always starts in rectum | Any GI tract, skip lesions |
| Histology key feature | Crypt abscesses, no granulomas | Non-caseating granulomas (pathognomonic) |
| Transmural? | No — mucosa only | Yes — fistulae, abscess, stricture |
| Most common EIM | Arthropathy (both types) | Arthropathy (both types) |
| PSC association | Yes — UC >> CD | Rare |
| B12 deficiency | Not specific | Terminal ileum disease — classic |
| Curative surgery | Yes — proctocolectomy | No — recurs post-resection |
| IPAA (J-pouch) | Preferred — curative | Avoid — high pouch failure rate |
| Activity score | Mayo score (0–12) | CDAI / Harvey-Bradshaw Index |
High-yield exam: Acute Severe UC = ≥6 bloody stools/day PLUS any one of: pulse >90, temp >37.8°C, Hb <105 g/L, ESR >30 mm/hr, CRP >30 mg/L
Oxford criteria: stools >8/day OR stools 3–8 + CRP >45 = 85% colectomy risk. Rescue therapy or surgery decision must be made by day 3.
| Drug Class | Agents | Mechanism | UC | CD | Key Nursing Point |
|---|---|---|---|---|---|
| Anti-TNF | Infliximab, Adalimumab | Blocks TNF-alpha | Yes | Yes | TB screening mandatory; infusion reactions (IFX) |
| Integrin inhibitor | Vedolizumab | Blocks gut lymphocyte homing (anti-alpha4beta7) | Yes | Yes | Gut-selective; lower systemic infection risk |
| IL-12/23 inhibitor | Ustekinumab | Blocks IL-12 and IL-23 (anti-p40) | Yes | Yes | SC maintenance after IV induction; good safety profile |
| JAK inhibitor | Tofacitinib, Upadacitinib | Inhibits JAK signalling | Yes | Upadacitinib CD | Oral; VTE, herpes zoster, cardiovascular risk warning |
| IL-23 selective | Risankizumab, Mirikizumab | Blocks IL-23 p19 subunit | Mirikizumab | Risankizumab | Newer agents; monthly SC after IV induction |
In ASUC, 24-hour stool count and blood content is reviewed each morning by the medical team. Incomplete documentation can delay rescue therapy decisions.
Log daily stool frequency to track trends over time. Useful for ASUC monitoring and outpatient flare detection.