Extensive small bowel disease

Extensive small bowel Crohn's disease

 

ECCO statement 5F (CD 2016)

Extensive small bowel Crohn’s disease should initially be treated with systemic corticosteroids, but early therapy with an anti-TNF based strategy should also be evaluated [EL5]. For patients with severe disease who have relapsed, an anti-TNF based strategy is appropriate [EL5]

Further information

Extensive small bowel disease defined as >100cm of inflammatory disease

  • Severity a composite of disease extent and activity. Objective scores exist to assess these criteria (e.g. MaRIA score; simple endoscopic score)
  • Extent usually determined by MRI
  • Activity determined by symptoms, biomarkers, and radiology (usually MRI)
  • Relapse within 3/12 uplifts severity to next category
Classify & quantify severity

Quiescent

Mild

Moderate

  • Severe disease represents CDAI >450 equivalent to Harvey Bradshaw >15
Severe

  • Review management of medically induced remission algorithm
  • Reassessment interval depends on disease course, patient preference and available resources
  • Reassess 3 – 6 monthly with biomarkers; with facility for urgent review if symptoms recur
  • Consider small bowel MR after 1 year, or if symptoms
  • Capsule endoscopy with prior patency capsule can be used in those with apparent quiescent disease
No Rx
Regular reassessment

ECCO statement 5G (CD 2016)

Patients who have clinical features suggesting a poor prognosis appear the most suitable for early introduction of immunosuppressive therapy. Early anti-TNF therapy [EL2] should be initiated in patients with high disease activity and features indicating a poor prognosis [EL3]

Further information

Adverse prognostic factors

 

  • Confirm active disease (consider need to re-evaluate extent). Step up therapy if relapse within 3 months. Treatment depends on duration of remission, concurrent therapy, adherence to therapy and patient preference
  • Relapse defined as CDAI>150 (HBI>4), with increase in CDAI >70-100 (increase in HBI >/= 3 points)
Relapse

ECCO statement 6C (CD 2016)

For patients with extensive disease, thiopurines are recommended for maintenance of remission [EL1]. In patients with aggressive/severe disease course or poor prognostic factors, an anti-TNF-based strategy should be considered [EL5]

Further information

There are no placebo controlled trials assessing primary nutritional therapy in adults so it should not be used except for patients who decline drug therapy. It has been shown to be inferior to steroid therapy. Elemental & polymeric diets have similar efficacy. Particularly consider nutritional therapy in those

  • still growing
  • malnourished (beware the re-feeding syndrome)
  • in whom medication contraindicated
Corticosteroids +/- thiopurines;
Consider adjunctive nutritional therapy

ECCO statement 5G (CD 2016)

Patients who have clinical features suggesting a poor prognosis appear the most suitable for early introduction of immunosuppressive therapy. Early anti-TNF therapy [EL2] should be initiated in patients with high disease activity and features indicating a poor prognosis [EL3]

ECCO statement 6C (CD 2016)

For patients with extensive disease, thiopurines are recommended for maintenance of remission [EL1]. In patients with aggressive/severe disease course or poor prognostic factors, an anti-TNF-based strategy should be considered [EL5]

Further information

There are no placebo controlled trials assessing primary nutritional therapy in adults so it should not be used except for patients who decline drug therapy. It has been shown to be inferior to steroid therapy. It is an important adjunctive therapy, including parenteral nutrition in complex, fistulating disease. Elemental & polymeric diets have similar efficacy. Particularly consider nutritional therapy in those

  • still growing
  • malnourished (beware the re-feeding syndrome)
  • in whom medication contraindicated
Corticosteroids and thiopurines;
Consider adjunctive nutritional therapy;
Consider Anti-TNF therapy if adverse prognostic factors

ECCO Statement 7C (CD 2016)

Strictureplasty is a safe alternative to resection in jejuno-ileal Crohn’s disease, including ileocolonic recurrence, with similar short-term and long-term results. Conventional strictureplasty is advised when the length of the stricture is <10 cm. However, in extensive disease with long strictured bowel segments where resection would compromise the effective small bowel length, non-conventional stricturoplasties may be attempted [EL3]

Further information

  • Surgery, preferably stricturoplasty to conserve bowel length, is appropriate for long-standing, predominately fibrotic disease. Surgery requires close liaison between patient, physician and surgeon; and must be considered at an early stage in complicated disease
  • Consider reviewing surgically induced remission of Crohn's disease algorithm
  • Surgery may be indicated in those who have been previously refractory to medical therapies e.g. anti-TNF
Consider surgery

ECCO statement 6B (CD 2016)

If a patient has a relapse, escalation of the maintenance treatment can be considered to prevent disease progression [EL2]. Steroids should not be used to maintain remission [EL1]. Surgery should always be considered as an option in localized disease [EL4]

Restart Algorithm

Reassess at 6-12 weeks

Reassess at 6 weeks

 

Persistent disease

Remission

Persistent disease

ECCO statement 6A (CD 2016)

After the first presentation if remission has been achieved with systemic steroids, a thiopurine [EL1] or methotrexate [EL3] should be considered. No maintenance treatment is an option for some patients [EL5]

Further information

Regular reassessment

ECCO statement 6C (CD 2016)

For patients with extensive disease, thiopurines are recommended for maintenance of remission [EL1]. In patients with aggressive/severe disease course or poor prognostic factors, an anti-TNF-based strategy should be considered [EL5]

Further information

Add or optimize anti-TNF

  • Confirm active disease (consider need to re-evaluate extent). Step up therapy if relapse within 3 months. Treatment depends on duration of remission, concurrent therapy, adherence to therapy and patient preference
  • Relapse defined as CDAI>150 (HBI>4), with increase in CDAI >70-100 (increase in HBI >/= 3 points)
Relapse

  • Deep remission usually defined as normal biomarkers (stool, serum) and normal endoscopic / radiological appearances
Long term, deep remission

ECCO statement 6B (CD 2016)

If a patient has a relapse, escalation of the maintenance treatment can be considered to prevent disease progression [EL2]. Steroids should not be used to maintain remission [EL1]. Surgery should always be considered as an option in localized disease [EL4]

Re-start algorithm

Consider stopping therapy

 

Abscess treatment

Abscess Treatment

ECCO Statement 7B (CD 2016)

Active small bowel Crohn’s disease with a concomitant abdominal abscess should preferably be managed with antibiotics, percutaneous or surgical drainage followed by delayed resection if necessary [EL3]

Further information

  • Sepsis suggested by fever and focal tenderness, mandating urgent imaging
  • Radiological drainage of abscess cavities > 3cm in diameter. Surgical drainage may be required
  • Provide antibiotics for at least 2-4 weeks; immunosuppressive treatment can be started once no evidence sepsis
  • Surgery can be an effective therapy for localized disease, mandating close liaison between patient, physician and surgeon; and must be considered at an early stage in complicated disease
Antibiotics and per-cutaneous (possibly surgical) drainage

ECCO Statement 7B (CD 2016)

Active small bowel Crohn’s disease with a concomitant abdominal abscess should preferably be managed with antibiotics, percutaneous or surgical drainage followed by delayed resection if necessary [EL3]

Delayed surgical resection

Remission

Persistent disease

Terms and conditions

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