Medical prophylaxis of postoperative Crohn disease
- Puneeta Tandon, MD, FRCPC
Puneeta Tandon, MD, FRCPC
- Associate Professor of Medicine
- University of Alberta, Canada
- Robert M Penner, BSc, MD, FRCPC, MSc
Robert M Penner, BSc, MD, FRCPC, MSc
- Assistant Clinical Professor
- University of Alberta, Canada
- Richard N Fedorak, MD, FRCPC
Richard N Fedorak, MD, FRCPC
- Professor of Medicine
- University of Alberta, Canada
Crohn disease is a chronic inflammatory bowel disease that results in significant morbidity and economic burden [1,2]. Surgical intervention rates are approximately 70 percent after ten years from diagnosis, although improvements in medical therapy may be decreasing the need for surgery [3,4]. The most common indications for surgery are failure of medical therapy and intestinal obstruction. The high rate of postoperative recurrence has stimulated multiple studies of prophylactic therapy.
This topic will discuss medical prophylaxis after surgery for patients with Crohn disease. Other aspects of the medical and surgical management of Crohn disease are discussed separately. (See "Surgical management of ulcerative colitis" and "Overview of the medical management of mild to moderate Crohn disease in adults" and "Immunomodulator therapy in Crohn disease" and "Infliximab in Crohn disease" and "Overview of the management of Crohn disease in children and adolescents" and "Overview of the medical management of severe or refractory Crohn disease in adults".)
Postoperative recurrence can be defined by endoscopic findings or clinical symptoms.
Endoscopic — Endoscopic recurrence precedes clinical recurrence. We therefore perform an endoscopic assessment 6 to 12 months following surgery to identify recurrence in low risk patients or in those reluctant to initiate early prophylactic therapy. Recurrence occurs most commonly at the site of surgical anastomosis and is characterized initially by aphthous and serpiginous ulceration . A meta-analysis of the placebo rates of severe endoscopic recurrence in postoperative Crohn disease estimated that among patients treated with placebo, the clinical relapse rate was 24 percent and the severe endoscopic recurrence rate was 50 percent .
Other studies have provided estimates of the time frame of endoscopic recurrence. In a cohort of 89 patients who had undergone ileal resection, endoscopic findings were present in 73 percent of patients within one year and 85 percent within three years of resection [5,7]. Similar findings were described in another report in which 72 percent of patients had endoscopic findings present after one year without a significant increase in recurrence in a 10-year period (77 percent) .
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- PREDICTORS OF RECURRENCE
- POSTOPERATIVE SURVEILLANCE
- MEDICAL PROPHYLAXIS
- Azathioprine and 6-mercaptopurine
- Other therapies
- - Probiotics
- - Anti-tumor necrosis factor agents
- - Elemental enteral nutrition
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS