Management of Crohn disease after surgical resection
- Robert M Penner, BSc, MD, FRCPC, MSc
Robert M Penner, BSc, MD, FRCPC, MSc
- Assistant Clinical Professor
- University of Alberta, Canada
- Puneeta Tandon, MD, FRCPC
Puneeta Tandon, MD, FRCPC
- Associate Professor of Medicine
- University of Alberta, Canada
- Richard N Fedorak, MD, FRCPC
Richard N Fedorak, MD, FRCPC
- Professor of Medicine
- University of Alberta, Canada
Crohn disease (CD) is a chronic inflammatory bowel disease that results in significant morbidity and economic burden [1,2]. Although advances in medical therapy have coincided with lower rates of surgical resection in patients with CD, surgical intervention is often required in the setting of bowel obstruction, abscesses or fistulas, or refractory disease. The 10-year risk of surgical resection for CD is nearly 50 percent .
While surgery often leads to clinical remission of CD, most patients ultimately relapse. The risk and severity of recurrence after surgical resection is variable and needs to be balanced with the potential risk of preventative medical therapy .
This topic will discuss the management of patients with CD following surgical resection. The American Gastroenterological Association has published guidelines on the management of CD after surgery, the contents of which are reflected in the subsequent discussions . Other aspects of the medical and surgical management of CD are discussed separately. (See "Overview of the medical management of mild to moderate Crohn disease in adults" and "Overview of the medical management of severe or refractory Crohn disease in adults" and "Operative management of Crohn disease of the small bowel, colon, and rectum".)
Flow of intestinal contents through the neo-terminal ileum and surgical anastomosis plays a significant role in recurrence [6,7]. In one report, three patients with CD who had undergone ileocolonic resection with ileocolonic anastomosis and temporary protective proximal loop ileostomy had no evidence of ileitis at six months after resection . However, infusion of the ileostomy contents into the bypassed ileal segment for seven days resulted in morphologic evidence of focal inflammation on ileal biopsy. Thus, intestinal contents including bile salts, digestive enzymes, bacteria, and dietary antigens may trigger the postoperative recurrence of ileal CD within the first days after surgery. These findings suggest that in select patients, medical therapy should begin soon after resection, and ileocolonic anastomosis are performed and continue indefinitely. (See 'Higher risk patients' below.)
POSTOPERATIVE RECURRENCE RATES
Surgery does not cure CD. Although clinical remission is often achieved, most patients eventually relapse. Recurrent disease can manifest by histologic or endoscopic findings or with clinical symptoms. Many patients will require subsequent surgery.
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- POSTOPERATIVE RECURRENCE RATES
- Histologic recurrence
- Clinical recurrence
- Endoscopic recurrence
- Surgical recurrence
- RISK FACTORS FOR RECURRENCE
- POSTOPERATIVE MONITORING
- Clinical followup
- MEDICAL PROPHYLAXIS
- Risk stratification
- - Lower risk patients
- - Higher risk patients
- - Anti-tumor necrosis factor agents
- - Other biologics
- - Azathioprine and 6-mercaptopurine
- - Antibiotics
- - Mesalamine
- GENERAL CARE FOR PATIENTS AFTER SURGERY
- Smoking cessation
- Health maintenance
- Screening for metabolic bone disease
- Infection risk
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS