Case 4 Discussion

Learning Objectives

  1. Recognize whether Crohn’s disease is low or high risk.
  2. Describe management options for limited ileal Crohn’s disease.
  3. Consider surgical resection for the patient with symptomatic short segment Crohn’s disease.

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 3: Prescribe and manage evidenced-based IBD therapies using clinical pharmacologic principles in clinical practice
  • EPA 6: Manage preoperative and postoperative care for patients with IBD

Discussion

  • Low risk Crohn’s disease: At the time of his diagnosis 6 months ago, he would have been considered to have low risk Crohn’s disease based on his older age at presentation (age > 30), limited anatomic involvement, absence of perianal or severe rectal disease, superficial ulcers, no prior surgical resection, and no stricturing and/or penetrating behavior.
  • Therapeutic options: In accordance with the current AGA care pathway for low-risk ileal Crohn’s, he was initially treated with a prednisone taper and azathioprine [1]. However, he has not achieved remission with initial therapy. His 6-thioguanine level suggests he is receiving a therapeutic dose of azathioprine (therapeutic range 230 and 450 picomoles/8 X 108 erythrocytes). Other therapy should be considered at this point:
    • Changing therapy to a biologic or surgical resection of his limited ileal disease. Current ACG guidelines recommend anti-TNF agents, anti-integrin therapy (e.g. vedolizumab), or ustekinumab for patients with Crohn’s disease who fail treatment with corticosteroids or thiopurines [2].
    • Surgery: Guidelines also recommend that surgery may be considered for patients with symptomatic Crohn’s disease localized to a short segment of bowel. This recommendation is supported by the results of a randomized trial of laparoscopic ileocecal resection versus infliximab for terminal ileitis in Crohn’s disease (LIR!C trial; [3]). Major inclusion criteria were active Crohn’s disease involving less than 40 cm of terminal ileum and non-response to at least 3 months of non-biologic therapy. Patients with abdominal abscesses were excluded. There was no significant difference between groups in the primary outcome of quality of life at 12 months. Over a 4-year median follow-up period, 37% of patients receiving infliximab ultimately underwent resection, and 26% of those who underwent resection ultimately received anti-TNF therapy. Retrospective long-term follow up from this study [4], showed similar results: none in the resection group required a second resection, and 42% did not require additional medication for Crohn’s disease. Stated another way, these results indicate that 74% of those who underwent resection did not require anti-TNF and 42% did not require any medication for Crohn’s disease after over 4 years of follow up, suggesting many low-risk patients with limited anatomic involvement may be able to maintain a durable remission after surgical resection.

Summary

Based on this data and current guidelines, laparoscopic ileocecal resection or biologic therapy are both reasonable options for this patient, and the choice should be individualized after discussion of the risks and benefits of each approach.

References

  1. Sandborn W et al. AGA Institute Guidelines for the Identification, Assessment and Initial Medical Treatment in Crohn’s Disease Clinical Decision Support Tool.
  2. Lichtenstein GR et al. ACG Clinical Guideline: Management of Crohn’s Disease in Adults. Am J Gastroentrol 2018;113(4):481-517.
  3. Ponsioen CY et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: a randomised controlled, open-label, multicentre trial. Lancet Gastroenterol Hepatol 2017 Nov;2(11):785-792.
  4. Stevens TW et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastroenterol Hepatol 2020 Jun 30.

 

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