Foregut disease

Foregut Crohn's Disease

ECCO statement 5H (CD 2016)

Mild oesophageal or gastroduodenal Crohn’s disease may be treated with a proton pump inhibitor only [EL5]. More severe or refractory disease requires additional systemic corticosteroids [EL4] or an anti-TNF based strategy [EL4]. Dilatation or surgery are appropriate for symptomatic stictures [EL4]

Further information

Increased prevalence in paediatric Crohn's disease patients

Foregut disease associated with adverse disease course: lowers threshold to escalate therapies

Considerations prior to treatment

  • 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
First drain abscess
if present

Conventional induction therapy + PPI. Eradicate H. pylori if present.

Symptomatic remission

 

Persistent symptoms

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

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

  • Little evidence base to guide therapy, but most physicians have lower threshold for anti-TNF given that foregut disease an adverse prognostic factor
  • Ensure H.pylori not present
Consider anti-TNF

  • 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

  • Confirm active disease. 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 within 3/12

 

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

 
 

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