The ‘3Rs’ of IBD: Recognition, Rating, and Referral
Recognize the type and rate the severity of inflammatory bowel diseases (IBD) such as ulcerative colitis or Crohn’s disease by how they first present. Refer patients with moderate-to-severe disease or complications to GI.
Ulcerative Colitis: Chronic Diarrhea >4 weeks, Biopsy Confirmation
Patients with ulcerative colitis (UC) commonly present with frequent loose stools mixed with blood or mucus. Symptoms usually emerge progressively over several weeks, and vary according to disease severity:
• Mild UC: Four or fewer loose stools per day (with or without blood), mild cramping, no systemic infection;
Most patients first present with mild UC. Approximately 27 percent present with moderate UC, and one percent present with severe UC.
Diagnostic criteria for UC are: chronic diarrhea for over four weeks, evidence of colitis based on endoscopy and biopsy, and exclusion of other causes of colitis through history and stool studies.
Crohn’s Disease: Chronic Diarrhea, Pain, Weight Loss
Crohn’s disease (CD) has a more variable presentation than UC. Classic symptoms include fatigue, prolonged diarrhea (with or without bleeding), crampy abdominal pain, weight loss, and fever. Patients may have symptoms for many years before diagnosis.
CD can affect any part of the gastrointestinal tract:
• 80 percent of patients have disease in the small bowel, usually the distal ileum;
Patients with CD also have a 33 percent increased risk of anal fistula after 10 years, and a 50 percent increased risk after 20 years. Up to 45 percent of patients with CD have a fistula before they are diagnosed.
In patients who have a clinical history consistent with CD, endoscopic biopsy, imaging (including barium studies, CT, or MRI), and laboratory tests can confirm the diagnosis and distinguish it from UC.
Refer Patients with Complications to a Colorectal Surgeon
For approximately 20 percent of patients with moderate-to-severe UC, medical management does not control the disease. Those patients and others with UC-related complications should see a colorectal surgeon for evaluation.
Patients who have complications of CD, including symptoms that are unresponsive to medical management, recurrent bowel obstruction, perforation, or anal fistula, should also be referred to a surgeon.
For Ulcerative Colitis:
Surgical treatment involves resection of the entire colon and rectum, usually through a laparoscopic approach. Surgeons construct an internal ileal pouch from the patient’s small bowel, which avoids the need for permanent ileostomy.
For Crohn’s Disease:
Surgical treatment involves resection of the severly affected area usually from stricture perforation or fistula. Care is taken to preserve as much of the bowel as possible since surgical cure is not possible and recurrence is high.
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