Crohn's Disease & Ulcerative Colitis Treatment in Mumbai

IBD management at Shree Hospitals is built around five structured clinical steps - from accurate diagnosis and disease phenotyping through to escalation of therapy when remission is not achieved, monitoring for complications and dysplasia, and surgical management for refractory or complicated disease. The IBD therapeutic landscape has been transformed over the past two decades by biologic agents that target specific inflammatory pathways, converting a condition that previously led reliably to surgery into one that most patients can manage medically for years to decades.

Step 1 - Endoscopic Diagnosis and Disease Phenotyping

Accurate diagnosis of Crohn's disease versus ulcerative colitis is critical because their management differs substantially. Colonoscopy with ileoscopy and segmental biopsies from each bowel segment is the primary diagnostic investigation. Ulcerative colitis produces continuous mucosal inflammation beginning at the rectum and extending proximally - the mucosa appears granular, friable, and ulcerated in active disease, with loss of the normal vascular pattern. Crohn's disease produces transmural inflammation in a discontinuous pattern - normal bowel between affected segments ("skip lesions"), cobblestone mucosal appearance in active disease, deep fissuring ulcers, and in advanced cases, fistulae and strictures. Ileoscopy is essential because the terminal ileum - the most common site of Crohn's disease - is inaccessible to standard colonoscopy without specifically advancing the scope through the ileocaecal valve. MRI enterography characterises the full extent of small bowel Crohn's disease beyond the reach of the colonoscope, assesses for strictures, fistulae, and mesenteric involvement, and is preferred over CT for ongoing monitoring due to the absence of ionising radiation.

Step 2 - Disease Severity Assessment and Biomarker Monitoring

Disease activity is assessed using validated clinical indices and objective biomarkers. Crohn's disease activity is quantified using the Harvey-Bradshaw Index or Crohn's Disease Activity Index (CDAI). UC severity uses the Mayo Clinic Score (endoscopic and clinical components combined). Stool calprotectin is the primary biomarker of intestinal inflammation - it correlates with endoscopic disease activity, reflects response to therapy, and is used to detect early flare before symptoms fully declare. CRP and erythrocyte sedimentation rate (ESR) are systemic inflammatory markers. Faecal calprotectin-guided monitoring allows reduction in unnecessary endoscopies while providing objective evidence of mucosal status between clinic visits.

Step 3 - Medical Therapy: Step-Up from Aminosalicylates to Immunomodulators and Biologics

UC is the primary indication for 5-aminosalicylic acid (5-ASA) therapy - mesalazine (oral and rectal preparations) induces and maintains remission in mild-to-moderate distal and left-sided UC. Mesalazine is not effective in Crohn's disease. Corticosteroids - oral prednisolone, budesonide (for ileocaecal Crohn's), and intravenous methylprednisolone for severe hospitalised flares - induce remission rapidly but cannot be used long-term due to metabolic and immune side effects. Steroid-dependent or steroid-refractory patients, and all patients with moderate-to-severe IBD, require immunomodulator therapy - azathioprine (2.5 mg/kg/day) or its active metabolite 6-mercaptopurine, or methotrexate for Crohn's - and biological therapy where immunomodulators fail or are not suitable. Thiopurine methyltransferase (TPMT) testing is performed before azathioprine to identify patients at risk of severe bone marrow toxicity.

Step 4 - Biologic Therapy and Small Molecule Agents

Biologic therapy has transformed IBD outcomes. Anti-TNF agents - infliximab (IV infusion) and adalimumab (subcutaneous injection) - were the first biologics approved for IBD and remain the most widely used, inducing mucosal healing in 40–60% of biologic-naive patients. Vedolizumab - a gut-selective anti-integrin antibody that blocks lymphocyte trafficking specifically to the intestinal mucosa - is preferred in patients where systemic immunosuppression is a concern. Ustekinumab - targeting the shared p40 subunit of IL-12 and IL-23 - is approved for both moderate-to-severe Crohn's disease and UC with a favourable safety profile. Tofacitinib (JAK1/3 inhibitor) is approved for moderate-to-severe UC. Therapeutic drug monitoring - measuring serum trough levels of infliximab and adalimumab and anti-drug antibody levels - guides dose optimisation and switching decisions to maximise biologic response durability.

Step 5 - Surgical Management and Dysplasia Surveillance

Surgery is required in approximately 20–30% of Crohn's patients within 10 years of diagnosis - primarily for stricturing disease causing bowel obstruction, penetrating disease with fistula or abscess, or medically refractory luminal disease. Bowel-conserving resection - removing the diseased segment with anastomosis - is preferred over extensive resection. In UC, proctocolectomy with ileal pouch-anal anastomosis (IPAA - "J-pouch") is the curative surgical option for medically refractory UC, UC complicated by toxic megacolon, or UC with confirmed high-grade dysplasia. Long-standing extensive UC (more than 8–10 years duration involving more than the left colon) carries an elevated colorectal cancer risk - annual surveillance colonoscopy with chromoendoscopy-guided biopsies is essential to detect dysplasia at its earliest and most treatable stage.