Surgically-induced remission

When reviewing this algorithm, bear in mind the following:

  • Course of disease – initial presentation, frequency & severity of flares
  • Extent of disease
  • Effectiveness and tolerance of previous treatments
  • Presence of biologic or endoscopic signs of inflammation

Most data has been derived following ileocolonic resection

Surgically-induced remission of Crohn's disease

ECCO statement 8E (CD 2016)

Calprotectin, “trans-abdominal” ultrasound, MR enterography, small bowel capsule endoscopy (SBCE) are less invasive diagnostic methods emerging as alternative tools for identifying postoperative recurrence [EL3]

Encourage smoking cessation

No prophylactic medical Rx

 

ECCO statement 8B (CD 2016)

The following are considered predictors of early post-operative recurrence after ileocolonic resection: smoking, prior intestinal surgery, absence of prophylactic treatment [EL1], penetrating disease at index surgery, perianal location [EL2], granulomas in resection specimen [EL2], and myenteric plexitis [EL3]

Further information

  • The use of post-operative anti-TNF or immune-modulators depends on prognostic factors relating to the likelihood of post-operative recurrence. These include
    • widespread disease (especially proximal small bowel disease)
    • perianal disease
    • time from diagnosis to first surgery (shorter being more severe)
    • smoking
    • penetrating disease
    • prior difficult-to-control disease
  • Prophylaxis is usually started after surgery
Prophylactic medical Rx needed

 
 

ECCO statement 8G (CD 2016)

Prophylactic treatment is recommended after ileocolonic intestinal resection in patients with at least one risk factor for recurrence [EL2]. To prevent post-operative recurrence the drugs of choice are thiopurines [EL2] or anti-TNFs [EL2]. High dose mesalazine is an option for patients with an isolated ileal resection [EL2]. Imidazole antibiotics have been shown to be effective after ileocolic resection but are less well tolerated [EL1]

ECCO statement 8H (CD 2016)

Long-term prophylaxis should be recommended [EL2]

Further information

  • High dose mesalazine less effective than thiopurine therapy
  • Imidazole antibiotics less effective and less well tolerated than thiopurines
  • Start prophylaxis within 2 weeks of surgery & continue longterm (Imidazoles for 3 months)
Thiopurine or anti-TNF if risk factors for recurrence; otherwise high dose mesalazine or imidazole antibiotics

ECCO statement 8B (CD 2016)

The following are considered predictors of early post-operative recurrence after ileocolonic resection: smoking, prior intestinal surgery, absence of prophylactic treatment [EL1], penetrating disease at index surgery, perianal location [EL2], granulomas in resection specimen [EL2], and myenteric plexitis [EL3]

Further information

Avoid risk factors associated with relapse:

  • Stop smoking (refer to smoking cessation service)
  • Avoid infectious gastroenteritis; provide dietary advice and nutritional support
  • Reduce “stress”: empower patients and consider need for psychological support
  • Ensure compliance with medical therapy
  • Optimise dose and type of medical therapy
  • Avoid NSAID use
Reduce risk factors

ECCO statement 6K (CD 2016)

Treatment with thiopurines is associated with an increased risk of lymphoma [EL1], non melanoma skin cancers [EL3], and cervical dysplasia [EL3]. Anti-TNF agents increase the risk of melanomas [EL3]. There is currently insufficient data to suggest that anti-TNF agents alone increase the risk of lymphoproliferative disorders or solid tumors. In contrast, their combination with thiopurines significantly increases the risk of lymphoproliferative disorders [EL3]. However, the absolute rates of these malignancies remain low and risks should always be balanced carefully against the substantial benefits associated with these treatments and discussed with the patient [EL5]

ECCO statement 8D (CD 2016)

Ileocolonoscopy is the gold standard in the diagnosis of postoperative recurrence by defining the presence and severity of morphologic recurrence and predicting the clinical course [EL2]. Ileocolonoscopy is recommended within the first year after surgery where treatment decisions may be affected [EL2]

ECCO statement 8E (CD 2016)

Calprotectin, “trans-abdominal” ultrasound, MR enterography, small bowel capsule endoscopy (SBCE) are less invasive diagnostic methods emerging as alternative tools for identifying postoperative recurrence [EL3]

Further information

  • Endoscopic recurrence occurs in 60-90% by 12 months; clinical recurrence without therapy occurs in 20-25% annually
  • Reassess between 3 & 12 months, dependent on course and extent of disease, with biomarkers and ileocolonoscopy and/or radiology; with facility for urgent review if symptoms recur
  • Ensure treatments optimized (correct therapy, correct dose, and compliance)
  • Measure serum vitamin B12 annually after ileal resection
Regular reassessment

Prevent associated disease

  • Diagnosis of recurrence usually suggested by clinical and biomarker assessment. Ileo-colonoscopy is the gold standard diagnostic modality
  • Relapse defined as CDAI>150 (HBI>4), with increase in CDAI >70-100 (increase in HBI >/= 3 points). If not present, consider alternative diagnoses (pain from adhesional obstruction or dysmotility; diarrhoea from bile salt malabsorbtion or bacterial overgrowth)
  • Post-operative recurrence is common: 65%-90% have endoscopic recurrence at 1 y; 80% - 100% at 3 y
  • Clinical recurrence occurs in 20-25%/y, in tandem with severe endoscopic lesions
Relapse

 

  • Remission for at least 1 year, with normal blood parameters, low faecal calprotectin, and healed mucosa
Long term, deep remission

 

Consider stopping medical therapy

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