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Acute severe ulcerative colitis is a serious condition, which is initially treated with high-dose corticosteroids. Failure to obtain remission should be detected within few days after treatment start, and a decision should be made whether to proceed with either cyclosporine or biological treatment, or to move on to emergency total colectomy with ileostomy. Most patients will later be candidates for a restorative proctocolectomy. Elective indications for restorative proctocolectomy are unresponsiveness to medical treatment, growth retardation in a child/adolescent, and neoplastic transformation. Crohn's disease is increasingly being treated with immunomodulators such as corticosteroids, thiopurines and biologics. These agents play a role both in inflammatory and fistulating diseases, but surgery continues to be important in obstructive and fistulating cases. Recurrences are frequently seen after bowel resection, and cessation of smoking has been shown to lower the risk of recurrence. High risk patients can be treated with thiopurines or biologics as a prophylactic measure to delay or prevent recurrence.

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