Ileocaecal Crohn's disease

Ileocaecal Crohn's Disease

Treat intercurrent stricturing and penetrating 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 defined by combination of SBMR and colonoscopy
  • Activity determined by symptoms, biomarkers, radiology (MR), colonoscopy & histology
  • Relapse within 3/12 uplifts severity to next category
  • Measure serum vitamin B12 annually
  • Consider bile salt malabsorbtion causing diarrhea, especially after terminal ileal resection
Assess severity

Quiescent

Mild

Moderate

  • Severe disease represents CDAI >450 equivalent to Harvey Bradshaw >15
  • Arrange surgical consultation to consider and discuss surgical treatment
Severe

No Rx

 

ECCO statement 5B (CD 2016)

Oral Budesonide is the preferred treatment [EL2]

Further information

Budesonide

  • Six-monthly review reasonable (possibly remotely) with facility for urgent review if symptoms recur
Regular reassessment

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]

ECCO statement 6D (CD 2016)

Immunosupressive naïve patients who are dependent on corticosteroids should be treated with a thiopurine [EL1] or methotrexate [EL2] or anti-TNF based strategy [EL1]. Surgical options should also be discussed [EL4]

Further information

Remission

  • Reassess by 3/12 or sooner if troublesome symptoms
  • Persistent disease also includes those who relapse within 3/12 or who have recurrent, frequent relapses
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]

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)
  • Exclude enteric infection including C. difficile.
Relapse

 
 

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

 
 
 

 

Moderate or Severe

Moderate or Severe

Moderate

  • Severe disease represents CDAI >450 equivalent to Harvey Bradshaw >15
  • Arrange surgical consultation to consider and discuss surgical treatment
Severe

Add immunomodulator if adverse prognostic factors

ECCO statement 5C (CD 2016)

Moderately active localised ileocaecal Crohn’s disease should be treated with budesonide [EL1], or with systemic corticosteroids [EL1]. An anti-TNF based strategy should be used as an alternative for patients, who have previously been steroid-refractory or –intolerant [EL1]. For some patients who have infrequently relapsing disease restarting steroids with an immunomodulator may be appropriate [EL2]. In patients refractory to steroids and/or anti-TNF, vedolizumab is an appropriate alternative [EL1]

Further information

  • Prednisolone is more effective than budesonide but causes more side-effects
  • Prednisolone is preferable if recent (failed) treatment with budesonide
  • Adjunctive nutritional therapy may be useful
Budesonide or corticosteroids

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 5D (CD 2016)

Severely active localised ileocaecal Crohn’s disease should initially be treated with systemic corticosteroids [EL1]. For those who have relapsed, an anti-TNF based strategy is appropriate [EL1]. Surgery is a reasonable alternative for patients with disease refractory to conventional medical treatment and should also be discussed [EL3]. For some patients who have infrequently relapsing disease restarting steroids with an immunomodulator may be appropriate [EL2]. In patients refractory to steroids and/or anti-TNF vedolizumab is an appropriate alternative [EL1]

ECCO Statement 7A (CD 2016)

Surgery is the preferred option in patients with localised ileocaecal Crohn’s disease with obstructive symptoms, but no significant evidence of active inflammation [EL4]

Further information

  • Corticosteroids not provided in those intolerant or refractory
  • Adjunctive nutritional therapy may be useful
  • The threshold for surgery in localized ileo-caecal disease is lower than for disease elsewhere. Obstructive, medically refractory localized ileo-caecal disease should be treated by surgery
  • The therapeutic strategy should be a joint decision between patient, physician and surgeon; and must be considered at an early stage in complicated disease
Corticosteroids; consider surgery

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

  • Those with </= 40cm affected bowel and CDAI>220 but no obstruction respond well to steroids. Eventually, they often require surgery.
  • Anti-TNF should additionally be provided to those with adverse prognostic factors and those who have failed steroid/immunomodulator therapy, assuming surgery is not indicated
  • Anti-TNF is not effective in absence objective disease (normal biomarkers and no mucosal disease)
Anti-TNF based strategy if adverse prognostic factors

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]

ECCO statement 6D (CD 2016)

Immunosupressive naïve patients who are dependent on corticosteroids should be treated with a thiopurine [EL1] or methotrexate [EL2] or anti-TNF based strategy [EL1]. Surgical options should also be discussed [EL4]

Further information

Remission

  • Reassess by 3/12 or sooner if troublesome symptoms
  • Persistent disease also includes those who relapse within 3/12 or who have recurrent, frequent relapses
Persistent disease
(incl. steroid-dependent,
-refractory or -intolerant)

Reassess by week 6

 

  • Six-monthly review reasonable (possibly remotely) with facility for urgent review if symptoms recur
Regular reassessment

 

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]

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)
  • Exclude enteric infection including C. difficile.
Relapse

 

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

  • Anti-TNF therapy associated 30% reduction at 1 y in surgery and hospitalization
Anti-TNF based strategy

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

 

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)
  • Exclude enteric infection including C. difficile.
Relapse after 3 months

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 (no need re-evaluate extent). Treatment depends on duration of remission, concurrent therapy, adherence to therapy and patient preference
Relapse within 3 months

 
 

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

  • Anti-TNF therapy associated 30% reduction at 1 y in surgery and hospitalization
Anti-TNF based strategy

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 of 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. Consider reviewing surgically induced remission of Crohn's disease algorithm
Antibiotics and per-cutaneous (possibly surgical) drainage

 

ECCO Statement 7A (CD 2016)

Surgery is the preferred option in patients with localised ileocaecal Crohn’s disease with obstructive symptoms, but no significant evidence of active inflammation [EL4]

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]

ECCO Statement 7F (CD 2016)

A laparoscopic approach is to be preferred for ileocolic resections in Crohn’s disease [EL 2] where appropriate expertise is available. In more complex cases or recurrent resection, there is insufficient evidence to recommended laparoscopic surgery as the technique of first choice [EL3]

Further information

  • Surgery an effective therapy, mandating close liaison between patient, physician and surgeon; and must be considered at an early stage in complicated disease. Laparoscopic rather than open resection recommended for non-complex disease. Consider reviewing surgically induced remission of Crohn's disease algorithm
  • 50% chance further operation never required
Delayed surgical resection

 

Remission

Persistent disease

Terms and conditions

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