Inflammatory bowel disease - NYSORA

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Inflammatory bowel disease

Learning objectives

  • Define inflammatory bowel disease
  • Describe the differences between Crohn’s disease and ulcerative colitis
  • Anesthetic management of a patient with inflammatory bowel disease

Definition and mechanisms

  • Inflammatory bowel disease (IBD) is a term for two conditions (Crohn’s disease and ulcerative colitis) that are characterized by chronic inflammation of the gastrointestinal (GI) tract
  • Prolonged inflammation results in damage to the GI tract
  • Caused by an interaction of environmental and genetic factors leading to immune responses and inflammation in the intestine → autoimmune disease
IBDCrohn’s diseaseUlcerative colitis
Affected locationCan affect any part of the GI tract (from mouth to anus), most often affects the portion of the small intestine before the large intestine (i.e., ileocecal region)Restricted to the large intestine (colon) and rectum
Damaged areasDamaged areas appear in patches that are next to areas of healthy tissueDamaged areas are continuous (not patchy), usually starting at the rectum and spreading further into the colon
InflammationInflammation may reach through the multiple layers of the walls of the GI tract → transmural inflammation leading to abscesses or granulomatous diseaseInflammation is present only in the innermost layer of the lining of the colon (i.e., mucosa) → loss of colonic mucosa

Signs and symptoms

  • Persistent diarrhea
  • Fatigue
  • Abdominal pain and cramping
  • Rectal bleeding, bloody stools
  • Reduced appetite
  • Unintended weight loss


Both conditions

Crohn’s disease

  • Bowel obstruction
  • Malnutrition
  • (Perianal) fistulas, may form an abscess
  • Anal fissure

Ulcerative colitis

  • Toxic megacolon
  • Perforated colon

Risk factors

  • Age
    • Most people are diagnosed before 30 years of age
    • Some people do not develop the disease until their 50-60s
  • White ethnicity
  • Family history
  • Smoking
  • NSAIDs medications (e.g., ibuprofen, naproxen sodium, diclofenac sodium)


Combination of endoscopy (for Crohn’s disease) or colonoscopy (for ulcerative colitis) and imaging studies

  • Contrast radiography
  • MRI
  • CT
  • Stool samples
  • Blood tests


  • Antidiarrheal medications (i.e., psyllium powder, methylcellulose, loperamide)
  • Anti-inflammatory drugs (i.e., glucocorticoids, 5-aminosalicylic acids)
  • Immunosuppressants (i.e., cyclosporine, azathioprine, mercaptopurine, methotrexate)
  • Antibiotics (i.e., ciprofloxacin, metronidazole)
  • Biologics (i.e., TNF-α inhibitor infliximab)
  • Nutritional support 
  • Surgery to remove damaged parts of the GI tract


inflammatory bowel disease, IBD, Crohn's disease, ulcerative colitis, preoperative, intraoperative, postoperative, management, enteral nutrition, steroid supplementation, adrenal insufficiency, cyclosporine, azathioprine, infliximab, malnutrition, glucose control, non-opioid analgesia, PONV, VTE prophylaxis, venous thromboembolism

IBD medication management during the perioperative period

GlucocorticoidsContinue; administer stress dose (see next table)
5-aminosalicylic acidDiscontinue on day of surgery and resume 3 days after surgery if normal renal function
Azathioprine, 6-mercaptopurineDiscontinue on day of surgery and resume 3 days after surgery if normal renal function
MethotrexateContinue unless previous poor wound healing or postoperative infections
CyclosporineContinue but carefully monitor for infectious complications
InfliximabContinue without interruption

Glucocorticoid management during the perioperative period

Axis suppressionMinor surgical stressModerate surgical stressMajor surgical stress
Prednisone < 5 mg/d
Glucocorticoids < 3 weeks
Negative corticotropin test
Daily dose
No supplementation
Daily dose
No supplementation
Daily dose
No supplementation
Documented or suspected
Prednisone > 10 mg/d for > 3 weeks
Positive corticotropin test
Daily dose
No supplementation
50 mg IV (induction)
25 mg IV every 8 hours for 24-48 hours
100 mg IV (induction)
50 mg IV every 8 hours for 24 hours
25 mg IV every 8 hours for 24-48 hours
Prednisone 5-10 mg ≥ 3 weeks
Daily dose
No supplementation
Positive corticotropin test
50 mg IV (induction)
25 mg IV every 8 hours for 24-48 hours
100 mg IV (induction)
50 mg IV every 8 hours for 24 hours
25 mg IV every 8 hours for 24-48 hours

See also perioperative steroids considerations

Suggested reading

  • Nickerson TP, Merchea A. Perioperative Considerations in Crohn Disease and Ulcerative Colitis. Clin Colon Rectal Surg. 2016;29(2):80-84.
  • Kumar A, Auron M, Aneja A, Mohr F, Jain A, Shen B. Inflammatory bowel disease: perioperative pharmacological considerations. Mayo Clin Proc. 2011;86(8):748-757.

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