Case 5 Discussion

Learning Objectives:

  1. Identify penetrating complications of Crohn’s disease.
  2. Describe appropriate management of intra-abdominal abscess in the setting of Crohn’s disease.
  3. List high risk factors for postoperative recurrence of Crohn’s disease.
  4. Select appropriate medical therapy for the post-operative patient with Crohn’s disease.

IBD EPAs

  • EPA 1: Classify IBD phenotype, disease activity, and extraintestinal manifestations

  • EPA 2: Use advanced diagnostic and therapeutic endoscopic and radiographic techniques in the management of IBD

  • EPA 4: Manage adverse events and complications of IBD and IBD therapies

  • EPA 5: Manage hospitalized patients with IBD

  • EPA 6: Manage preoperative and postoperative care for patients with IBD 

 

I. Surgery vs. Biologic Therapy for Intra-abdominal Abscess:

Current ACG guidelines state that surgery is required to treat enteric complications of Crohn’s disease [1]. The most common indication for bowel resection in CD is small bowel obstruction due to fibrostenotic stricture, followed by complications of penetrating CD, as in this case of a patient with an intra-abdominal abscess due to multiple internal fistulae from an inflamed segment of ileum. In the case of intra-abdominal abscess, percutaneous drainage is the preferred initial treatment if feasible. In combination with antibiotics, this may allow control of intra-abdominal sepsis, which in turn allows for bowel resection in a clean rather than contaminated operation, increasing the likelihood that primary anastomosis may be safely performed [2]. Failure to resect the involved segment following resolution of intra-abdominal abscess is associated with increased risk of recurrent abscess. It has been suggested that biologic therapy can be considered as primary therapy in cases of small abscess (< 6 cm), with no associated stricture, new onset Crohn’s disease with no prior surgery, a short single segment of intestinal involvement (< 15 cm), and absence of perianal disease [3]. Even when these criteria are fulfilled, most patients whose disease has progressed to the point of developing internal fistulae with abscess will require surgery at some point in the future. While some of these favorable features are present in this patient and a trial of biologic therapy can be considered, given the stricture with pre-stenotic dilation, this patient will be best served with limited ileal resection once the acute infection has been cooled down with antibiotics.

II. Risk of Postoperative Crohn’s Recurrence:

The highest risk factors for postoperative recurrence of Crohn’s disease are active tobacco smoking after surgery, penetrating Crohn’s disease, and at least 2 prior surgeries for CD. Greater disease extent, age < 30, and shorter disease duration prior to surgery have also been associated with increased risk of recurrence. Compared to penetrating CD, stricturing disease is considered to carry lower risk of recurrence. NSAID use has been associated with CD flares but has not been definitively linked to postoperative CD recurrence. Use of biologics prior to surgery for Crohn’s disease has not been associated with increased infection and a washout period is not required. Use of biologics prior to surgery for Crohn’s disease has not been associated with increased infection and a washout period is not required. However, their use preoperatively has not been associated with increased risk for recurrence. Finally, among surgical techniques, side-to-side anastomosis of an ileocolic resection is associated with lower recurrence compared to end-to-end anastomosis [4].

III. Management of Postoperative Crohn’s Disease:

ACG guidelines states that risk factors for postoperative Crohn’s disease recurrence should be considered when deciding on treatment. Mesalamine is of limited benefit in preventing postoperative CD. Antibiotics (specifically imidazole antibiotics) have been shown to decrease the risk of recurrence compared to placebo, but this benefit is lost when the antibiotic is stopped [5]. Thiopurines are more effective than mesalamine or placebo for preventing recurrence, however, they may not prevent severe endoscopic recurrence [6]. Current evidence suggests that anti-TNF therapy is the most effective treatment to prevent postoperative recurrence, and current guidelines recommend that anti-TNF be started within 4 weeks of surgery for high-risk patients [7]. Consideration should also be given to combination therapy with an immunomodulator to decrease immunogenicity and loss of response to the anti-TNF. There is less data for newer biologic agents with respect to risk of post-operative recurrence, however, in one retrospective study, vedolizumab was associated with a higher rate of postoperative recurrence of CD than anti-TNF therapy [8]. Colonoscopy is recommended 6-12 months after surgery to monitor for endoscopic recurrence, which precedes clinical recurrence. The Rutgeerts score is used to predict clinical recurrence based on endoscopic findings:

  • i0: no lesions, normal appearing neo-terminal ileum
  • i1: <5 aphthous ulcers in the neo-terminal ileum
  • i2a: lesions confined to the anastomosis +/- <5 aphthous ulcers in the neo-terminal ileum
  • i2b: >5 aphthous ulcers in the neo-terminal ileum with normal intervening mucosa +/- anastomotic lesions
  • i3: diffuse aphthous ileitis with diffusely inflamed mucosa
  • i4: diffuse inflammation with large ulcers, nodules and/or narrowing

Endoscopic remission is defined as a score of i0 or i1, and is associated with <5% risk of clinical recurrence at 3 years. A Rutgeerts score of i2a or i2b or greater should prompt initiation of medical therapy, if not already started, or change in therapy [9,10].

References

  1. Lichtenstein GR et al. ACG Clinical Guideline: Management of Crohn’s Disease in Adults. Am J Gastroentrol 2018;113(4):481-517.
  2. Poritz LS, Koltun WA. Percutaneous drainage and ileocolectomy for spontaneous intraabdominal abscess in Crohn’s disease. J Gastrointest Surg. 2007;11(2)204-208.
  3. Bouguen G et al. Efficacy and Safety of Tumor Necrosis Factor Antagonists in Treatment of Internal Fistulizing Crohn’s Disease. Clin Gastroenterol Hepatol 2020;18(3)628-636.
  4. Scarpa M et al. Surgical predictors of recurrence of Crohn’s disease after ileocolonic resection. Int J Colorectal Dis. 2007;22(9):1061.
  5. Rutgeerts P et al. Ornidazole for prophylaxis of postoperative Crohn’s disease recurrence: a randomized, double-blind, placebo-controlled trial. Gastroenterology 2005;128:856-861.
  6. Doherty G et al. Interventions for prevention of post-operative recurrence of Crohn’s disease. Cochrane Database Syst Rev 2009;(4):Cd006873.
  7. Singh S et al. Comparative efficacy of pharmacologic interventions in preventing relapse of Crohn’s disease after surgery: a systematic review and network meta-analysis. Gastroenterology 2015;148:64-76.
  8. Yamada A et al. The Use of Vedolizumab in Preventing Postoperative Recurrence of Crohn’s Disease. Inflamm Bowel Dis. 2018;24(3)502-509.
  9. Rutgeerts P et al. Predictability of the postoperative course of Crohn’s disease. Gastroenterology 1990;99(4):956-63.
  10. Riviere P et al. No Change in Determining Crohn’s Disease Recurrence or Need for Endoscopic or Surgical Intervention With Modification of the Rutgeerts’ Scoring System. Clin Gastroenterol Hepatol 2019;17(8):1643-1645.

 

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