Crohn Disease Guidelines

Updated: Jul 26, 2019
  • Author: Leyla J Ghazi, MD; Chief Editor: Praveen K Roy, MD, MSc  more...
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Guidelines Summary

American College of Gastroenterology

In 2018, the American College of Gastroenterology published the following guidelines on the management of Crohn disease in adults [149] :

  • Fecal calprotectin is a helpful test that should be considered to help differentiate the presence of inflammatory bowel disease (IBD) from irritable bowel syndrome (IBS).
  • In patients at particularly high risk for colorectal neoplasia (eg, personal history of dysplasia, primary sclerosing cholangitis), chromoendoscopy should be used during colonoscopy, as it may increase the diagnostic yield for detection of colorectal dysplasia, especially compared with standard-definition white light endoscopy.
  • For patients undergoing surveillance colonoscopy, there is insufficient evidence to recommend universal chromoendoscopy for IBD colorectal neoplasia surveillance if the endoscopist has access to high-definition white light endoscopy.
  • Narrow-band imaging should not be used during colorectal neoplasia surveillance examinations for Crohn disease.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) may exacerbate disease activity and should be avoided when possible in patients with Crohn disease.
  • Cigarette smoking exacerbates disease activity and accelerates disease recurrence and should be avoided.
  • Use of antibiotics should not be restricted in Crohn disease patients in order to prevent disease flares.
  • Perceived stress, depression, and anxiety, which are common in IBD, are factors that lead to decreased health-related quality of life in patients with Crohn disease and lead to lower adherence to provider recommendations. Assessment and management of stress, depression, and anxiety should be included as part of the comprehensive care of the Crohn disease patient.
  • Sulfasalazine is effective for treating symptoms of colonic Crohn disease that is mild to moderately active and can be used as treatment for this patient population.
  • Controlled ileal release budesonide at a dose of 9 mg once daily is effective and should be used for induction of symptomatic remission for patients with mild to moderate ileocecal Crohn disease.
  • Metronidazole is not more effective than placebo as therapy for luminal inflammatory Crohn disease and should not be used as primary therapy.
  • For patients with low risk of progression, treatment of active symptoms with antidiarrheals, other nonspecific medications, and dietary manipulation, along with careful observation for inadequate symptom relief, worsening inflammation, or disease progression, is acceptable.
  • Oral corticosteroids are effective and can be employed for short-term use in alleviating signs and symptoms of moderately to severely active Crohn disease. Thiopurines (azathioprine, 6-mercaptopurine) are effective and should be considered for use for steroid sparing in Crohn disease.
  • Azathioprine and 6-mercaptourine are effective therapies and should be considered for treatment of patients with Crohn disease for maintenance of remission
  • Thiopurine methyltransferase (TPMT) testing should be considered before initial use of azathioprine or 6-mercaptopurine to treat patients with Crohn disease.
  • Methotrexate (up to 25 mg once weekly intramuscularly [IM] or subcutaneously [SC]) is effective and should be considered for use in alleviating signs and symptoms in patients with steroid-dependent Crohn disease and for maintaining remission.
  • Anti–tumor necrosis factor (anti-TNF) agents (infliximab, adalimumab, certolizumab pegol) should be used to treat Crohn disease that is resistant to treatment with corticosteroids.
  • Anti-TNF agents should be given for Crohn disease refractory to thiopurines or methotrexate.
  • Combination therapy of infliximab with immunomodulators (thiopurines) is more effective than treatment with either immunomodulators alone or infliximab alone in patients who are naive to those agents.
  • For patients with moderately to severely active Crohn disease and objective evidence of active disease, anti-integrin therapy (with vedolizumab) with or without an immunomodulator is more effective than placebo and should be considered for use in induction of symptomatic remission in patients with Crohn disease.
  • Natalizumab is more effective than placebo and should be considered for use in induction of symptomatic response and remission in patients with active Crohn disease.
  • Natalizumab should be used for maintenance of natalizumab-induced remission of Crohn disease only if serum antibody to John Cunningham (JC) virus is negative. Testing for anti-JC virus antibody should be repeated every 6 months and treatment stopped if the result is positive.
  • Ustekinumab should be given for moderate to severe Crohn disease patients who failed previous treatment with corticosteroids, thiopurines, methotrexate, or anti-TNF inhibitors or who have had no prior exposure to anti-TNF inhibitors.
  • Intravenous corticosteroids should be used to treat severe or fulminant Crohn disease.
  • Anti-TNF agents (infliximab, adalimumab, certolizumab pegol) can be considered to treat severely active Crohn disease.
  • Infliximab may be administered to treat fulminant Crohn disease. Infliximab is effective and should be considered in treating perianal fistulas in Crohn disease. Infliximab may be effective and should be considered in treating enterocutaneous and rectovaginal fistulas in Crohn disease.
  • Adalimumab and certolizumab pegol may be effective and should be considered in treating perianal fistulas in Crohn disease.
  • Thiopurines (azathioprine, 6-mercaptopurine) may be effective and should be considered in treating fistulizing Crohn disease.
  • The addition of antibiotics to infliximab is more effective than infliximab alone and should be considered in treating perianal fistulas.
  • Drainage of abscesses (surgically or percutaneously) should be undertaken before treatment of fistulizing Crohn disease with anti-TNF agents.
  • Once remission is induced with corticosteroids, a thiopurine or methotrexate should be considered.
  • Anti-TNF therapy, specifically infliximab, adalimumab, and certolizumab pegol, should be used to maintain remission of anti-TNF–induced remission.
  • Anti-TNF monotherapy is effective at maintaining anti-TNF–induced remission, but because of the potential for immunogenicity and loss of response, combination with azathioprine/6-mercaptopurine or methotrexate should be considered.
  • Imidazole antibiotics (metronidazole and ornidazole) at doses between 1 and 2 g/day can be used after small intestinal resection in Crohn disease patients to prevent recurrence.
  • In high-risk patients, anti-TNF agents should be started within 4 weeks of surgery in order to prevent postoperative Crohn disease recurrence.
  • An intra-abdominal abscess should be treated with antibiotics and a drainage procedure, either radiographically or surgically.

Crohn disease radiologic evaluation

In 2017, an expert panel, which included contributors from the Society of Abdominal Radiology Crohn’s Disease–Focused Panel, the Society of Pediatric Radiology, and the American Gastroenterological Association, issued the following guidelines on the use of computed tomography enterography (CTE) and magnetic resonance enterography (MRE) in patients with small bowel Crohn disease [150, 151] :

  • The number of involved bowel segments and their location, as well as the length and degree of upstream dilatation of Crohn strictures, should be reported by radiologists to help gastroenterologists and surgeons determine the best therapeutic plan.
  • Radiologists should state if mural inflammation is present when describing areas with stricture or penetrating disease.
  • Cross-sectional enterography should be performed at Crohn disease diagnosis.
  • Consider cross-sectional enterography for disease monitoring in patients with small bowel disease or penetrating complications.
  • While a dedicated pelvic magnetic resonance (MR) study is needed in patients with perianal disease, all CTEs and MREs should also include imaging of the anus.
  • Radiologists should comment on and describe intramural T2 hyperintensity, restricted diffusion, perienteric stranding, wall thickness, and mural ulcerations seen on imaging, because they typically correlate with disease severity.
  • MRE is preferred over CTE to estimate response to medical treatment in patients with asymptomatic disease.
  • Noncontrast MRE with T2-weighted and diffusion-weighted imaging is an “acceptable alternative” when intravenous contrast agents cannot be used.
  • Radiologists should evaluate CTE and MRE examinations for signs of mesenteric venous thrombosis, occlusions, or small bowel varices.