Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Management of Crohn disease after surgical resection

Robert M Penner, BSc, MD, FRCPC, MSc
Puneeta Tandon, MD, FRCPC
Richard N Fedorak, MD, FRCPC
Section Editor
Paul Rutgeerts, MD, PhD, FRCP
Deputy Editor
Kristen M Robson, MD, MBA, FACG


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 [3].

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 [4].

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 [5]. 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 [6]. 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.)


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.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: May 2017. | This topic last updated: Jun 14, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Longobardi T, Jacobs P, Bernstein CN. Work losses related to inflammatory bowel disease in the United States: results from the National Health Interview Survey. Am J Gastroenterol 2003; 98:1064.
  2. Wolters FL, Russel MG, Stockbrügger RW. Systematic review: has disease outcome in Crohn's disease changed during the last four decades? Aliment Pharmacol Ther 2004; 20:483.
  3. Frolkis AD, Dykeman J, Negrón ME, et al. Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies. Gastroenterology 2013; 145:996.
  4. Ananthakrishnan AN. Surgery for Crohn's disease: look harder, act faster. Lancet 2015; 385:1370.
  5. Nguyen GC, Loftus EV Jr, Hirano I, et al. American Gastroenterological Association Institute Guideline on the Management of Crohn's Disease After Surgical Resection. Gastroenterology 2017; 152:271.
  6. D'Haens GR, Geboes K, Peeters M, et al. Early lesions of recurrent Crohn's disease caused by infusion of intestinal contents in excluded ileum. Gastroenterology 1998; 114:262.
  7. Rutgeerts P, Goboes K, Peeters M, et al. Effect of faecal stream diversion on recurrence of Crohn's disease in the neoterminal ileum. Lancet 1991; 338:771.
  8. Swoger JM, Regueiro M. Evaluation for postoperative recurrence of Crohn disease. Gastroenterol Clin North Am 2012; 41:303.
  9. Rutgeerts P, Hiele M, Geboes K, et al. Controlled trial of metronidazole treatment for prevention of Crohn's recurrence after ileal resection. Gastroenterology 1995; 108:1617.
  10. Lochs H, Mayer M, Fleig WE, et al. Prophylaxis of postoperative relapse in Crohn's disease with mesalamine: European Cooperative Crohn's Disease Study VI. Gastroenterology 2000; 118:264.
  11. Renna S, Cammà C, Modesto I, et al. Meta-analysis of the placebo rates of clinical relapse and severe endoscopic recurrence in postoperative Crohn's disease. Gastroenterology 2008; 135:1500.
  12. Fumery M, Dulai PS, Meirick P, et al. Systematic review with meta-analysis: recurrence of Crohn's disease after total colectomy with permanent ileostomy. Aliment Pharmacol Ther 2017; 45:381.
  13. Rutgeerts P, Geboes K, Vantrappen G, et al. Predictability of the postoperative course of Crohn's disease. Gastroenterology 1990; 99:956.
  14. Olaison G, Smedh K, Sjödahl R. Natural course of Crohn's disease after ileocolic resection: endoscopically visualised ileal ulcers preceding symptoms. Gut 1992; 33:331.
  15. Frolkis AD, Lipton DS, Fiest KM, et al. Cumulative incidence of second intestinal resection in Crohn's disease: a systematic review and meta-analysis of population-based studies. Am J Gastroenterol 2014; 109:1739.
  16. Strong S, Steele SR, Boutrous M, et al. Clinical Practice Guideline for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2015; 58:1021.
  17. Ryan WR, Allan RN, Yamamoto T, Keighley MR. Crohn's disease patients who quit smoking have a reduced risk of reoperation for recurrence. Am J Surg 2004; 187:219.
  18. Yamamoto T. Factors affecting recurrence after surgery for Crohn's disease. World J Gastroenterol 2005; 11:3971.
  19. Cottone M, Orlando A, Modesto I. Postoperative maintenance therapy for inflammatory bowel disease. Curr Opin Gastroenterol 2006; 22:377.
  20. Papay P, Reinisch W, Ho E, et al. The impact of thiopurines on the risk of surgical recurrence in patients with Crohn's disease after first intestinal surgery. Am J Gastroenterol 2010; 105:1158.
  21. Reese GE, Nanidis T, Borysiewicz C, et al. The effect of smoking after surgery for Crohn's disease: a meta-analysis of observational studies. Int J Colorectal Dis 2008; 23:1213.
  22. Alvarez-Lobos M, Arostegui JI, Sans M, et al. Crohn's disease patients carrying Nod2/CARD15 gene variants have an increased and early need for first surgery due to stricturing disease and higher rate of surgical recurrence. Ann Surg 2005; 242:693.
  23. Sachar DB, Wolfson DM, Greenstein AJ, et al. Risk factors for postoperative recurrence of Crohn's disease. Gastroenterology 1983; 85:917.
  24. Poggioli G, Laureti S, Selleri S, et al. Factors affecting recurrence in Crohn's disease. Results of a prospective audit. Int J Colorectal Dis 1996; 11:294.
  25. Raab Y, Bergström R, Ejerblad S, et al. Factors influencing recurrence in Crohn's disease. An analysis of a consecutive series of 353 patients treated with primary surgery. Dis Colon Rectum 1996; 39:918.
  26. D'Haens GR, Gasparaitis AE, Hanauer SB. Duration of recurrent ileitis after ileocolonic resection correlates with presurgical extent of Crohn's disease. Gut 1995; 36:715.
  27. Bernell O, Lapidus A, Hellers G. Risk factors for surgery and postoperative recurrence in Crohn's disease. Ann Surg 2000; 231:38.
  28. Regueiro M, Velayos F, Greer JB, et al. American Gastroenterological Association Institute Technical Review on the Management of Crohn's Disease After Surgical Resection. Gastroenterology 2017; 152:277.
  29. Simillis C, Yamamoto T, Reese GE, et al. A meta-analysis comparing incidence of recurrence and indication for reoperation after surgery for perforating versus nonperforating Crohn's disease. Am J Gastroenterol 2008; 103:196.
  30. Avidan B, Sakhnini E, Lahat A, et al. Risk factors regarding the need for a second operation in patients with Crohn's disease. Digestion 2005; 72:248.
  31. Borley NR, Mortensen NJ, Chaudry MA, et al. Recurrence after abdominal surgery for Crohn's disease: relationship to disease site and surgical procedure. Dis Colon Rectum 2002; 45:377.
  32. Sampietro GM, Corsi F, Maconi G, et al. Prospective study of long-term results and prognostic factors after conservative surgery for small bowel Crohn's disease. Clin Gastroenterol Hepatol 2009; 7:183.
  33. Sachar DB, Lemmer E, Ibrahim C, et al. Recurrence patterns after first resection for stricturing or penetrating Crohn's disease. Inflamm Bowel Dis 2009; 15:1071.
  34. Scarpa M, Ruffolo C, Bertin E, et al. Surgical predictors of recurrence of Crohn's disease after ileocolonic resection. Int J Colorectal Dis 2007; 22:1061.
  35. Bernell O, Lapidus A, Hellers G. Recurrence after colectomy in Crohn's colitis. Dis Colon Rectum 2001; 44:647.
  36. Ghosh S, D'Haens G. Is an Ounce of Prevention Worth a Pound of Cure: Postoperative Recurrence of Crohn's Disease? Gastroenterology 2016; 150:1521.
  37. De Cruz P, Kamm MA, Hamilton AL, et al. Crohn's disease management after intestinal resection: a randomised trial. Lancet 2015; 385:1406.
  38. Blum E, Katz JA. Postoperative therapy for Crohn's disease. Inflamm Bowel Dis 2009; 15:463.
  39. Hashash JG, Regueiro M. A Practical Approach to Preventing Postoperative Recurrence in Crohn's Disease. Curr Gastroenterol Rep 2016; 18:25.
  40. McLeod RS, Wolff BG, Steinhart AH, et al. Risk and significance of endoscopic/radiological evidence of recurrent Crohn's disease. Gastroenterology 1997; 113:1823.
  41. Achkar JP, Shen B. Medical management of postoperative complications of inflammatory bowel disease: pouchitis and Crohn's disease recurrence. Curr Gastroenterol Rep 2001; 3:484.
  42. Kotanagi H, Kramer K, Fazio VW, Petras RE. Do microscopic abnormalities at resection margins correlate with increased anastomotic recurrence in Crohn's disease? Retrospective analysis of 100 cases. Dis Colon Rectum 1991; 34:909.
  43. de Jong E, van Dullemen HM, Slors JF, et al. Correlation between early recurrence and reoperation after ileocolonic resection in Crohn's disease: a prospective study. J Am Coll Surg 1996; 182:503.
  44. De Cruz P, Kamm MA, Prideaux L, et al. Postoperative recurrent luminal Crohn's disease: a systematic review. Inflamm Bowel Dis 2012; 18:758.
  45. D'Haens GR, Vermeire S, Van Assche G, et al. Therapy of metronidazole with azathioprine to prevent postoperative recurrence of Crohn's disease: a controlled randomized trial. Gastroenterology 2008; 135:1123.
  46. Busti AJ, Hooper JS, Amaya CJ, Kazi S. Effects of perioperative antiinflammatory and immunomodulating therapy on surgical wound healing. Pharmacotherapy 2005; 25:1566.
  47. Doherty G, Bennett G, Patil S, et al. Interventions for prevention of post-operative recurrence of Crohn's disease. Cochrane Database Syst Rev 2009; :CD006873.
  48. Regueiro M, Feagan BG, Zou B, et al. Infliximab Reduces Endoscopic, but Not Clinical, Recurrence of Crohn's Disease After Ileocolonic Resection. Gastroenterology 2016; 150:1568.
  49. Regueiro M, Schraut W, Baidoo L, et al. Infliximab prevents Crohn's disease recurrence after ileal resection. Gastroenterology 2009; 136:441.
  50. Sorrentino D, Terrosu G, Avellini C, Maiero S. Infliximab with low-dose methotrexate for prevention of postsurgical recurrence of ileocolonic Crohn disease. Arch Intern Med 2007; 167:1804.
  51. Papamichael K, Archavlis E, Lariou C, Mantzaris GJ. Adalimumab for the prevention and/or treatment of post-operative recurrence of Crohn's disease: a prospective, two-year, single center, pilot study. J Crohns Colitis 2012; 6:924.
  52. Yoshida K, Fukunaga K, Ikeuchi H, et al. Scheduled infliximab monotherapy to prevent recurrence of Crohn's disease following ileocolic or ileal resection: a 3-year prospective randomized open trial. Inflamm Bowel Dis 2012; 18:1617.
  53. Savarino E, Dulbecco P, Bodini G, et al. Prevention of postoperative recurrence of Crohn's disease by Adalimumab: a case series. Eur J Gastroenterol Hepatol 2012; 24:468.
  54. Aguas M, Bastida G, Cerrillo E, et al. Adalimumab in prevention of postoperative recurrence of Crohn's disease in high-risk patients. World J Gastroenterol 2012; 18:4391.
  55. De Cruz P, Kamm MA, Hamilton AL, et al. Efficacy of thiopurines and adalimumab in preventing Crohn's disease recurrence in high-risk patients - a POCER study analysis. Aliment Pharmacol Ther 2015; 42:867.
  56. Regueiro M, Kip KE, Baidoo L, et al. Postoperative therapy with infliximab prevents long-term Crohn's disease recurrence. Clin Gastroenterol Hepatol 2014; 12:1494.
  57. Savarino E, Bodini G, Dulbecco P, et al. Adalimumab is more effective than azathioprine and mesalamine at preventing postoperative recurrence of Crohn's disease: a randomized controlled trial. Am J Gastroenterol 2013; 108:1731.
  58. Takeshima F, Yoshikawa D, Higashi S, et al. Clinical efficacy of adalimumab in Crohn's disease: a real practice observational study in Japan. BMC Gastroenterol 2016; 16:82.
  59. Kotze PG, Yamamoto T, Danese S, et al. Direct retrospective comparison of adalimumab and infliximab in preventing early postoperative endoscopic recurrence after ileocaecal resection for crohn's disease: results from the MULTIPER database. J Crohns Colitis 2015; 9:541.
  60. Preda CM, Fulger LE, Negreanu L, et al. Adalimumab versus infliximab in treating post-operative recurrence of Crohn's disease: a national cohort study. Rev Esp Enferm Dig 2016; 108:642.
  61. Peyrin-Biroulet L, Deltenre P, Ardizzone S, et al. Azathioprine and 6-mercaptopurine for the prevention of postoperative recurrence in Crohn's disease: a meta-analysis. Am J Gastroenterol 2009; 104:2089.
  62. Herfarth HH, Katz JA, Hanauer SB, et al. Ciprofloxacin for the prevention of postoperative recurrence in patients with Crohn's disease: a randomized, double-blind, placebo-controlled pilot study. Inflamm Bowel Dis 2013; 19:1073.
  63. Rutgeerts P, Van Assche G, Vermeire S, et al. Ornidazole for prophylaxis of postoperative Crohn's disease recurrence: a randomized, double-blind, placebo-controlled trial. Gastroenterology 2005; 128:856.
  64. Gordon M, Naidoo K, Thomas AG, Akobeng AK. Oral 5-aminosalicylic acid for maintenance of surgically-induced remission in Crohn's disease. Cochrane Database Syst Rev 2011; :CD008414.
  65. Ford AC, Kane SV, Khan KJ, et al. Efficacy of 5-aminosalicylates in Crohn's disease: systematic review and meta-analysis. Am J Gastroenterol 2011; 106:617.
  66. Caprilli R, Cottone M, Tonelli F, et al. Two mesalazine regimens in the prevention of the post-operative recurrence of Crohn's disease: a pragmatic, double-blind, randomized controlled trial. Aliment Pharmacol Ther 2003; 17:517.