Ulcerative colitis (UC) and Crohn’s disease (CD) (collectively termed inflammatory bowel disease (IBD)) are complex disorders reflected by wide variation in clinical practice. These guidelines, commissioned by the Clinical Services’ Committee of the British Society of Gastroenterology (BSG) for clinicians and allied professionals caring for patients with IBD in the United Kingdom, provide an evidence based document describing good clinical practice for investigation and treatment. The guidelines are intended to bring consistency, but should not necessarily be regarded as the standard of care for all patients. Individual cases must be managed on the basis of all clinical data available for that case. Patient preferences should be sought and decisions jointly made between patient and health professional.

### 1.1 Development of guidelines

A comprehensive literature search was performed using electronic databases (Medline, PubMed, and Ovid; keywords: “inflammatory bowel disease”, “ulcerative colitis”, and “Crohn’s disease”) by Dr Carter. A preliminary document was drafted by Dr Carter, Dr Lobo, and contributing authors. This was summarised by Dr Travis and revised after circulation first to the committee and then to members of the IBD section of the BSG, before submission to the Clinical Services’ Committee.

### 1.2 Grading of recommendations1

The guidelines conform to the North of England evidence based guidelines development project. The grading of each recommendation is dependent on the category of evidence supporting it:





### 1.3 Scheduled review of guidelines

The content and evidence base …

https://gut.bmj.com/content/gutjnl/53/suppl_5/v1.full.pdf

Guidelines for the management of inflammatory bowel disease in adults

Objective: To investigate the effect of a restricted intravenous fluid regimen versus a standard regimen on complications after colorectal resection. Summary Background Data: Current fluid administration in major surgery causes a weight increase of 3‐ 6 kg. Complications after colorectal surgery are reported in up to 68% of patients. Associations between postoperative weight gain and poor survival as well as fluid overload and complications have been shown. Methods: We did a randomized observer-blinded multicenter trial. After informed consent was obtained, 172 patients were allocated to either a restricted or a standard intraoperative and postoperative intravenous fluid regimen. The restricted regimen aimed at maintaining preoperative body weight; the standard regimen resembled everyday practice. The primary outcome measures were complications; the secondary measures were death and adverse effects. Results: The restricted intravenous fluid regimen significantly reduced postoperative complications both by intention-to-treat (33% versus 51%, P 0.013) and per-protocol (30% versus 56%, P 0.003) analyses. The numbers of both cardiopulmonary (7% versus 24%, P 0.007) and tissue-healing complications (16% versus 31%, P 0.04) were significantly reduced. No patients died in the restricted group compared with 4 deaths in the standard group (0% versus 4.7%, P 0.12). No harmful adverse effects were observed. Conclusion: The restricted perioperative intravenous fluid regimen aiming at unchanged body weight reduces complications after elective colorectal resection.

Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial.

The management of inflammatory bowel disease represents a key component of clinical practice for members of the British Society of Gastroenterology (BSG). There has been considerable progress in management strategies affecting all aspects of clinical care since the publication of previous BSG guidelines in 2004, necessitating the present revision. Key components of the present document worthy of attention as having been subject to re-assessment, and revision, and having direct impact on practice include: The data generated by the nationwide audits of inflammatory bowel disease (IBD) management in the UK in 2006, and 2008. The publication of 'Quality Care: service standards for the healthcare of people with IBD' in 2009. The introduction of the Montreal classification for Crohn's disease and ulcerative colitis. The revision of recommendations for the use of immunosuppressive therapy. The detailed analysis, guidelines and recommendations for the safe and appropriate use of biological therapies in Crohn's disease and ulcerative colitis. The reassessment of the role of surgery in disease management, with emphasis on the importance of multi-disciplinary decision-making in complex cases. The availablity of new data on the role of reconstructive surgery in ulcerative colitis. The cross-referencing to revised guidelines for colonoscopic surveillance, for the management of metabolic bone disease, and for the care of children with inflammatory bowel disease. Use of the BSG discussion forum available on the BSG website to enable ongoing feedback on the published document http://www.bsg.org.uk/forum (accessed Oct 2010). The present document is intended primarily for the use of clinicians in the United Kingdom, and serves to replace the previous BSG guidelines in IBD, while complementing recent consensus statements published by the European Crohn's and Colitis Organisation (ECCO) https://www.ecco-ibd.eu/index.php (accessed Oct 2010).

https://gut.bmj.com/content/gutjnl/60/5/571.full.pdf

aDepartment of Pharmacology and Therapeutics, University of Porto; MedInUP, Centre for Drug Discovery and Innovative Medicines; Centro Hospitalar São João, Porto, Portugal bIBD Unit, DIMEC, University of Bologna, Bologna, Italy cDepartment of Gastroenterology and Hepatology, Chaim Sheba Medical Center, Tel Hashomer, Israel dGastrointestinal Unit ASST Fatebenefratelli Sacco—University of Milan—Milan, Italy eIBD Unit Complesso Integrato Columbus, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli Universita’ Cattolica del Sacro Cuore, Rome, Italy fDepartment of Gastroenterology, IBD Unit, University Hospital Santiago De Compostela (CHUS), A Coruña, Spain gDepartment of Gastroenterology, North Zealand University Hospital, Frederikssund, Denmark hFirst Department of Medicine, Semmelweis University, Budapest, Hungary iIBD Unit, St Mark’s Hospital, Middlesex, UK jDepartment of Gastroenterology, University Hospital of Ghent, Ghent, Belgium kInstitute of Pathology, Medical University of Graz, Graz, Austria lDepartment of Gastroenterology, Pennine Acute Hospitals NHS Trust; Institute of Inflammation and Repair, University of Manchester, Manchester, UK mUnit of General Surgery, Second University of Naples, Napoli, Italy nMaria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Department of Oncological Gastroenterology Warsaw; Medical Centre for Postgraduate Education, Department of Gastroenterology, Hepatology and Clinical Oncology, Warsaw, Poland oDepartment of Medicine, University of Cambridge, Cambridge, UK pImperial College London; Chelsea and Westminster Hospital, London, UK qDepartment of Pathobiology /NC22, Lerner Research Institute; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

/pdf/third-european-evidence-based-consensus-on-diagnosis-and-2g4pj48jlg.pdf

Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: Definitions, Diagnosis, Extra-intestinal Manifestations, Pregnancy, Cancer Surveillance, Surgery, and Ileo-anal Pouch Disorders.

http://pic2.cmt.com.cn/WebImages/Res/20121218/20121218_07b349d6-2637-4801-bdbd-4fb2c4b2a867.pdf

Management of Crohn's Disease in Adults

Levator syndrome is a symptom complex of severe pain and pressure in the anorectal area. Electrogalvanic stimulation (EGS) has been proposed as a treatment for this condition. Several reports have described EGS as up to 90 percent “effective” in treating levator syndrome, but the length of follow-up was uncertain or short-term in these studies. The purpose of this study was to examine the long-term benefits of EGS in levator syndrome patients treated at one institution. All patients undergoing EGS for levator syndrome between 1985 and 1991 were studied. Initial complaints, physical examination, number of treatments, procedure tolerance, and long-term benefit were determined through personal interviews and chart reviews. There were 52 patients (63 percent females and 37 percent males) with a median age of 54 years (range, 24–84 years). All patients presented with anorectal pain. Tenderness was localized by examination to the left in 43 percent, to the right in 23 percent, and bilateral in 8.6 percent and was not localized in 2.6 percent. Fifty percent received fewer than four one-hour treatments, 33 percent received four to six treatments, and 17 percent received more than six treatments. Seventy-seven percent felt that the treatment was painless. Follow-up results were as follow: number, 52; percent follow-up, 88; mean follow-up, 28 months (range, 0–71 months); symptoms relieved, 19 percent; partial relief, 24 percent; no relief, 57 percent. Of four patients with a wrong diagnosis, three were ultimately diagnosed with recurrent pelvic cancer and one had an anal fissure. At our institution, EGS was a tolerable treatment, but a substantial number of patients received no benefit. An organic etiology of anorectal pain must always be excluded.

Electrogalvanic stimulation for levator syndrome: how effective is it in the long-term?

In a retrospective review of 311 patients having subtotal colectomy for ulcerative colitis, information on the fate of the rectal stump was obtained in 288. Proctectomy was performed in 159 patients (55 percent); for persistent proctitis in 118 (41 percent), cancer prophylaxis in 37 (13 percent), and cancer in four (1.4 percent). One hundred twenty-two patients (42 percent) had ileorectal anastomoses. Eighty-four of these (69 percent) retained a functioning ileorectal anastomosis at the time of follow-up or death, one to 22 years later, and an additional six patients (5 percent) had a satisfactory ileorectal anastomosis for five to 14 years before proctectomy. Cancer developed in the rectal stump in nine patients (3.1 percent), underscoring the need for either proctectomy (total or mucosal) or long-term surveillance of the retained rectum. However, subtotal colectomy, by permitting ileorectal anastomosis or other sphincter-preserving surgery at a later date, does have a definite place in many patients requiring surgery for ulcerative colitis.

The fate of the rectal stump after subtotal colectomy for ulcerative colitis.

Increasing numbers of polyposis registries have led to more young patients being diagnosed with familial adenomatous polyposis (FAP). To provide guidelines for selecting the appropriate surgical procedure in teenagers (10–19 years), we compared the results of colectomy and ileo-rectal anastomosis (IRA, n=17 patients) to the results of resrorative proctocolectomy and ileal pouch-anal anastomosis (IPAA, n=7 patients). Charts were reviewed to obtain data on the operative technique, blood loss and transfusions, hospital stay (including the time for ileostomy closure), and early (within 30 days of surgery) and late complications. Functional results (bowel movements per 24h, use of antidiarrheal drugs, seepage, and fecal incontinence) and quality of life were evaluated prospectively with a questionnaire and physical examination. The median follow-up time was 49 months (range, 6 to 95 months) after IRA, and 36 months after IPAA (range, 4 to 87 months). Although restorative proctocolectomy and IPAA, is a longer (5.75 vs 3.1 hours), more bloody (500 vs 300 mL blood loss), and more complex operation with a longer hospital stay (12 vs 7 days) than IRA (P=0.008, P=0.006, P=0.02, respectively), no significant difference (P>0.05) was found between groups concerning the complication rate or quality of life. For teenagers with FAP and rectal carpeting, large rectal adenomas, curable cancer in the upper two-thirds of the rectum, or who are unavailable for follow-up, we recommend a restorative proctocolectomy and IPAA. For the other patients, the decision whether to perform IRA or restorative proctocolectomy with IPAA depends on the patient's desire and the surgeon's skill.

Surgery for the teenager with familial adenomatous polyposis: ileo-rectal anastomosis or restorative proctocolectomy?

Background: The insertion of a colonoscope to the caecum is a difficult technique to teach and to learn. The most commonly used criterion for proficiency is completion rate and early experience is often discouraging. In order to document the learning curve and better define normal progress for the early learning experience, the performance of trainees during their first 100–125 cases was recorded.



Methods: The completion rate and time for office colonoscopy were recorded prospectively over a 5-year period for each of 18 trainees. Trainees’ experience was analysed in groups of 25 cases, numbered chronologically. Completion rate was defined as the number of examinations completed to the caecum by the trainee expressed as a percentage of the number completed by the staff.



Results: The mean overall completion rate for trainees was 56.4% (range 27.8–83.9%). For the first five groups of 25 cases, the percentage completion rates (in order from first 25 cases to fifth 25 cases) were 43.1, 52.6, 49.3, 61.8 and 75.1%, respectively. There was a wide variation in completion rates between trainees, but no difference in time taken. (Time for trainees to complete the procedure, in order from the first 25 cases to fifth 25 cases: 18.7, 19.1, 19.4, 17.6 and 17.1 min, respectively.)



Conclusions: Early experience in colonoscopy can be discouraging. At least 100 cases are needed to attain a level of proficiency that enables completion in two-thirds of cases, whereas 125 cases lead to an average completion rate of 75%.

Colonoscopy training: the need for patience (patients).

PURPOSE: A case of a patient with familial adenomatous polyposis (FAP) is reported, in whom adenomas developed in an ileal pelvic pouch six years after it was made. This case is reported to serve as a warning that restorative proctocolectomy, a relatively recent addition to surgical options for FAP, does not remove the risk of metachronous intestinal neoplasia; it merely defers it. METHODS: Case of a patient with pouch polyposis was reviewed, and patient was prospectively studied after three months of sulindac therapy. RESULTS: Polyps not removed at first examination became much less prominent. Literature review reveals only one study of adenomas in pelvic pouches, with 7 cases of 38. CONCLUSION: Proctocolectomy and ileal pouch-anal anastomosis does not cure FAP, and multiple polyps can occur in the ileal pouch.

John R. Oakley

Papers

Electrogalvanic stimulation for levator syndrome: how effective is it in the long-term?

The fate of the rectal stump after subtotal colectomy for ulcerative colitis.

Surgery for the teenager with familial adenomatous polyposis: ileo-rectal anastomosis or restorative proctocolectomy?

Colonoscopy training: the need for patience (patients).

Pouch polyposis after ileal pouch-anal anastomosis for familial adenomatous polyposis: report of a case.