Nutrition, steroids and biologics around surgery

Synopsis

Build a practical perioperative IBD optimisation plan that measures malnutrition and sepsis, uses enteral support when feasible, minimises corticosteroid exposure without adrenal interruption, and makes drug-specific biologic decisions without delaying source control.

Screen every surgical IBD patient for recent weight loss, BMI, intake, muscle loss, anaemia and micronutrient deficiency; albumin also reflects inflammation and should not be used as a stand-alone nutrition score.
Use oral food and supplements first when safe, then enteral tube feeding if intake remains inadequate; parenteral nutrition is reserved for a non-functioning or inaccessible gut or failure of enteral delivery.
For mildly malnourished patients undergoing major gastrointestinal surgery, cited ESPEN practice supports 7–10 days of preoperative nutrition; severe malnutrition may justify longer delay when the disease is safe to defer.

Key red flags

Shock, peritonism, faeculent vomiting, absolute constipation, rising lactate, free gas or reduced bowel-wall enhancement indicates threatened or established bowel and overrides elective optimisation.

Fever or an undrained abscess before immunosuppressive treatment requires infection and source-control review.

New hypotension, hyponatraemia, hypoglycaemia, vomiting or profound weakness after corticosteroid interruption raises adrenal insufficiency and needs urgent treatment.

Reasoning priorities

Weight history, BMI and validated malnutrition screen

Quantify recent loss and identify who needs urgent dietetic assessment and preoperative support.

An apparently stable BMI does not exclude sarcopenia; percentage weight loss and reduced intake change urgency and route.

Worked reasoning

Worked case: nutrition and steroid optimisation before Crohn surgeryConvert measured deficits into a time-limited plan

A 34-year-old with an 8 cm fibrotic terminal-ileal Crohn stricture has three partial obstructions in two months. CT enterography shows no abscess or fistula. Weight has fallen from 69 kg to 63.5 kg in three months (8.0%), BMI is 19.1 kg/m², intake is about half usual, CRP 24 mg/L and haemoglobin 104 g/L. They have taken prednisolone 20 mg daily for six weeks and adalimumab; surgery is elective but should not drift indefinitely.

The colorectal surgeon, gastroenterologist and dietitian confirm a fixed short stricture without uncontrolled sepsis, quantify weight loss and intake, check iron indices, B12, folate, vitamin D, magnesium and phosphate, and document the exact steroid and adalimumab dates.
The dietitian prescribes a low-residue oral diet plus liquid enteral supplements for ten days because the patient can pass stool and retain liquids. A patient-specific target is 1900 kcal and 85 g protein daily; intake charts show 82% of energy and 88% of protein target by day 4 without vomiting.
Iron studies show ferritin 8 micrograms/L and transferrin saturation 9%, so the anaemia team gives ferric carboxymaltose 1000 mg IV over 15 minutes with product monitoring. The IBD team reduces prednisolone to 15 mg daily only after confirming stability. Medication history shows adalimumab 40 mg SC every two weeks, last given seven days ago; with no infection or abscess the MDT continues it preoperatively rather than imposing a washout. For this patient, recent nutritional depletion and continuing steroid exposure lead the MDT to choose a brief postoperative hold while assessing wound healing and infection risk against the risk of Crohn relapse; this is an individual elective-surgery decision, not a universal instruction to stop biologics for IBD surgery.
At day 10 weight is 64.2 kg, phosphate and magnesium remain normal, haemoglobin is 111 g/L, CRP is 13 mg/L and the patient walks 400 m without stopping. Anaesthesia, stoma care and thromboprophylaxis plans are complete, and surgery proceeds rather than extending optimisation without a defined benefit.
Because six weeks of prednisolone leaves glucocorticoid-induced adrenal insufficiency unexcluded and ileocaecal resection is major surgery, anaesthesia gives hydrocortisone 100 mg IV at induction then 200 mg over each 24 hours while nil by mouth. Once uncomplicated enteral recovery is established, give double the pre-surgical prednisolone dose—30 mg daily—for 48 hours, then return to 15 mg and resume the IBD taper. Following the individual MDT plan, the adalimumab dose due during early postoperative recovery is withheld and treatment is restarted on postoperative day 14 only after the wound is healed, sutures are out and there is no drainage, erythema, swelling, organ-space infection or other active infection. Pathology confirms a fibrotic stricture; oral intake meets target by day 4 and day-30 review verifies no leak or abscess and records the actual biologic restart.

Ulcerative colitis on anti-TNF before elective surgeryAvoid an automatic biologic washout

A 42-year-old with dysplasia in ulcerative pancolitis is clinically stable on infliximab, takes no corticosteroid and has no fever, collection or other active infection. Elective proctocolectomy is planned two weeks after the next scheduled infusion.

Key medicines

Perioperative hydrocortisone: maintenance conversion and major-surgery coverFor maintenance arithmetic, prednisolone 5 mg equals hydrocortisone 20 mg; therefore prednisolone 20 mg/day equals hydrocortisone 80 mg/day. This is not the whole major-surgery plan. In an adult taking prednisolone at least 5 mg/day for at least 4 weeks with unexcluded HPA suppression, corrected Woodcock Table 2 uses hydrocortisone 100 mg IV at induction followed immediately by 200 mg/24 hours by continuous IV infusion while nil by mouth, then double the pre-surgical enteral glucocorticoid dose for 48 hours if recovery is uncomplicated.Document dose, duration, recent courses, operation magnitude and oral absorption with anaesthetic/endocrine input. The 200 mg/24-hour stress infusion covers the nil-by-mouth period; do not add a separate calculated maintenance infusion unless the specialist plan explicitly requires it. Monitor infection, glucose, blood pressure, sodium, potassium, mental state and wound healing, and taper from the defined transition rather than stopping abruptly.

Ferric carboxymaltose for the worked iron-deficiency caseFor the 63.5 kg adult with haemoglobin 10.4 g/dL in the worked case, the Ferinject simplified table gives a total need of 1000 mg. Give 1000 mg iron (20 mL) as one IV infusion over at least 15 minutes, diluted only in no more than 250 mL compatible 0.9% sodium chloride and maintaining at least 2 mg iron/mL; the dose is below 20 mg/kg and the 1000 mg weekly maximum.Confirm iron deficiency and exclude hypersensitivity to parenteral iron. Administer where anaphylaxis can be treated, observe for at least 30 minutes, avoid extravasation and monitor phosphate when repeated high doses or risk factors make hypophosphataemia likely. A routine preoperative full blood count can assess readiness, but formal haemoglobin reassessment of iron repletion should be at least 4 weeks after the final Ferinject dose.

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