Colonic Crohn's disease

ECCO statement 5E (CD 2016)

Active colonic CD should be treated with systemic corticosteroids [EL1]. For those who have relapsed, an anti-TNF based strategy is an appropriate option [EL1]. In patients refractory to steroids and/or anti-TNF vedolizumab is an appropriate alternative [EL1]

Further information

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
Colonic Crohn's Disease

Assess severity & phenotype

  • Sepsis suggested by fever and focal tenderness, mandating urgent imaging
  • Organize 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 ongoing sepsis
First drain abscess if present

  • Extensive colitis is inflammation proximal and distal to the splenic flexure and often patchy
  • Sub-defined as macroscopic and/or microscopic disease
Extensive disease

Quiescent

ECCO statement 5E (CD 2016)

Active colonic CD should be treated with systemic corticosteroids [EL1]. For those who have relapsed, an anti-TNF based strategy is an appropriate option [EL1]. In patients refractory to steroids and/or anti-TNF vedolizumab is an appropriate alternative [EL1]

Further information

Mild

Moderate

  • Disease activity defined by objective assessment (biomarkers, endoscopy, histology, radiology)
  • Severe disease represents CDAI >450 equivalent to Harvey Bradshaw > 15
Severe

Quiescent or Mild

Quiescent or Mild

Quiescent

 

ECCO statement 5E (CD 2016)

Active colonic CD should be treated with systemic corticosteroids [EL1]. For those who have relapsed, an anti-TNF based strategy is an appropriate option [EL1]. In patients refractory to steroids and/or anti-TNF vedolizumab is an appropriate alternative [EL1]

Further information

Mild

No treatment

 

Corticosteroids
(budesonide if only proximal colonic disease)
+ immunomodulator if poor prognostic features

  • Review management of medically induced remission algorithm
  • Reassessment interval depends on disease course, patient preference and available resources
  • Six-monthly review reasonable (possibly remotely) with facility for urgent review if symptoms recur
Regular reassessment

 

Assessment

  • Confirm active disease (consider need to re-evaluate extent)
  • 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)
  • Exclude pathogens which may cause symptoms or induce flares of disease, eg CMV, C. difficile
Relapse

Remission

Persistent disease

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

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 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]

Further information

  • Confirm active disease (consider need to re-evaluate extent). 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

 
 

Mild relapse

Moderate or severe 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

  • Consider optimizing immunomodulator before starting anti-TNF
  • Consider corticosteroid course before starting anti-TNF if prolonged steroid-induced remission
Consider corticosteroids. Add / optimize immunomodulator therapy in extensive disease

Moderate or Severe

Moderate or Severe

ECCO Statement 7G (CD 2016)

If surgery is necessary for localised colonic disease (less than a third of the colon involved) then resection of the affected part only is preferable [EL3]. Two segmental resections can be considered for a patient with an established indication for surgery when macroscopic disease affects two separate segments of the colon [EL3]. Strictureplasty in the colon is not recommended [EL3]

Further information

  • Diverting the faecal stream allows healing of more distal disease, pending anti-TNF or novel therapies
  • Segmental resection of localized disease (<1/3 of colon) or two segmental resections if disease affects both ends of the colon is preferable to proctocolectomy, mandating 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
Possible defunction for symptom control

ECCO statement 5E (CD 2016)

Active colonic CD should be treated with systemic corticosteroids [EL1]. For those who have relapsed, an anti-TNF based strategy is an appropriate option [EL1]. In patients refractory to steroids and/or anti-TNF vedolizumab is an appropriate alternative [EL1]

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

  • Reassess disease activity after 4-6 week (sooner if severe) to exclude steroid-refractory disease (defined as non-response to steroids or relapse within 3 months of stopping steroids) and after 3 months to exclude steroid-dependence (daily prednisolone >/=10mg (Budesonide >/= 3mg) beyond 3 months)
  • Adjunctive nutritional therapy may be useful
Corticosteroids and immunomodulator;
+ anti-TNF or surgery if poor prognostic factors

  • Sepsis suggested by fever and focal tenderness, mandating urgent imaging
  • Organize 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 ongoing sepsis
First drain abscess if present.
Consider surgery

Regular reassessment

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

Continue immunomodulator. Regular assessment.

 

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]

ECCO Statement 7G (CD 2016)

If surgery is necessary for localised colonic disease (less than a third of the colon involved) then resection of the affected part only is preferable [EL3]. Two segmental resections can be considered for a patient with an established indication for surgery when macroscopic disease affects two separate segments of the colon [EL3]. Strictureplasty in the colon is not recommended [EL3]

Further information

  • Anti-TNF and immunomodulator more effective than either agent alone. Consider initiating anti-TNF with, or within weeks of, starting immunomodulator
  • Segmental surgical resection of localized disease may be preferable in patients with long-standing, predominately fibrotic disease . This requires close liaison between patient, physician and surgeon; and must be considered at an early stage in complicated disease. It is not known whether (prophylactic) anti-TNF should be provided following surgery. Consider reviewing surgically induced remission of Crohn's disease algorithm
  • Laparoscopic assisted panproctocolectomy may be required in extensive Crohn’s colitis
Add anti-TNF;
+/- 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]

Further information

  • Confirm active disease (consider need to re-evaluate extent). 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

 

Remission

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]

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

 

Regular reassessment

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