Key Points
- Nearly one-half of patients with Crohn’s disease (CD) will require bowel resection within the first 10 years of disease.
- However, surgery is not curative, and one-fourth of these patients will require at least another bowel resection within five years of index surgery.
- Surgical recurrence is usually preceded by endoscopic and clinical recurrence. Endoscopic recurrence can occur in the neoterminal ileum in as many as 90% of patients within 12 months of surgical resection.
- Certain clinical features, such as the presence of penetrating disease, cigarette smoking, and multiple prior resections, are risk factors for disease recurrence.
- The presence and severity of endoscopic recurrence, as measured by the Rutgeerts’ score, is a strong predictor of clinical and surgical recurrence.
- The prevention of postoperative disease recurrence is a high priority given the morbidity associated with clinical and surgical recurrence and the long-term risk of short gut syndrome that may arise from multiple bowel resections.
Management
Rutgeerts’ Scoring Index for Endoscopic Recurrence Assessed in the Neoterminal Ileum
- i0, no lesionsa
- i1, <5 aphthous lesionsa
- i2, >5 aphthous lesions with normal intervening mucosa
- i3, diffuse aphthous ileitis with diffusely inflamed mucosa
- i4, diffuse inflammation with large ulcers, nodules, and/or narrowing. Rutgeerts’ scores of i0 and i1 are considered endoscopic remission, whereas Rutgeerts’ scores of i2, i3 and i4 are considered endoscopic recurrence. Note that ulceration limited to the anastomosis, but not in the neoterminal ileum, is not considered endoscopic recurrence of CD.
aConsidered endoscopic remission.
Recommendations for the Management of Crohn’s Disease After Surgical Resection
| Statement | Strength of recommendation | Quality of evidence |
|---|---|---|
| In patients with surgically induced remission of CD, AGA suggests early pharmacological prophylaxis over endoscopy-guided pharmacological treatment. Comments: Patients, particularly those at lower risk of recurrence, who place a higher value on avoiding the small risks of adverse events from pharmacological prophylaxis and a lower value on the potential risk of early disease recurrence may reasonably select endoscopy-guided pharmacological treatment over prophylaxis. | Conditional | Very low quality |
| In patients with surgically induced remission of CD, AGA suggests using anti-TNF therapy and/or thiopurines over other agents. Comments: Patients at lower risk of disease recurrence or who place a higher value on avoiding the small risk of adverse events of thiopurines or anti-TNF treatment and a lower value on a modestly increased risk of disease recurrence may reasonably choose nitroimidazole antibiotics (for 3–12 months). | Conditional | Moderate |
| In patients with surgically induced remission of CD, AGA suggests against using mesalamine (or other 5-aminosalicylates), budesonide, or probiotics. | Conditional | Low; very low |
| In patients with surgically induced remission of CD receiving pharmacological prophylaxis, AGA suggests postoperative endoscopic monitoring at 6–12 months after surgical resection over no monitoring. | Conditional | Moderate |
| In patients with surgically induced remission of CD not receiving pharmacological prophylaxis, AGA recommends postoperative endoscopic monitoring at 6–12 months after surgical resection over no monitoring. | Strong | Moderate |
| In patients with surgically induced remission of CD with asymptomatic endoscopic recurrence, AGA suggests initiating or optimizing anti-TNF and/or thiopurine therapy over continued monitoring alone. Comments: Patients who place a higher value on avoiding the small risk of adverse events of thiopurines or anti-TNF treatment and a lower value on the increased risk of clinical recurrence following asymptomatic endoscopic recurrence may reasonably choose continued endoscopic monitoring. | Conditional | Moderate |
Management Algorithma
