The evolving management of postoperative Crohn's disease

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Date: Sept. 2012
Publisher: Expert Reviews Ltd.
Document Type: Report
Length: 8,891 words
Lexile Measure: 1410L

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Author(s): Jana G Hashash [*] 1 , Miguel D Regueiro 2

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5-aminosalicylates; 6-mercaptopurine; anti-TNF therapy; azathioprine; Crohn's disease; immunomodulator; infliximab; postoperative recurrence; surgery

There is no known cure for Crohn's disease. A Crohn's disease patient is transiently 'cured' immediately after surgical resection of the affected bowel. Recurrence of disease may occur as early as 7 days after surgery [1] . Everyday questions posed by patients and clinicians managing postoperative Crohn's disease are: how should we monitor for disease recurrence? Are there risk factors that predict which patient will develop recurrence? What can we do to maintain remission and prevent postoperative recurrence?

Crohn's disease is a chronic inflammatory bowel condition. Despite advances in treatment strategies as well as early and aggressive utilization of those medications, at least one surgical intervention remains inevitable in the majority of patients [2-11] . Reasons for surgery include severe active disease that is resistant to medical therapy or complications of Crohn's disease such as perforation, fistulization, stricture formation, abscesses and rarely, malignancy [5-7] . Of the patients who undergo intestinal surgical resection, up to 90% exhibit evidence of endoscopic Crohn's recurrence within 1 year of surgery [12,13] . The site of recurrence tends to be the neoterminal ileum, just above and proximal to the ileocolonic anastomosis. A total of 30% of patients manifest in symptomatic clinical recurrence at 3 years, 50% at 5 years and 60% at 10 years postintestinal resection [5] . Up to 70% of patients will require a second surgical resection by 10 years after the initial resection. The indications for subsequent surgeries tend to be similar to that of the index surgery, that is, obstructing strictures, perforating disease, and so on [10,12,14-17] . Due to the high postoperative recurrence rates, it is important to identify risk factors for recurrence of postoperative Crohn's disease and stratify treatment accordingly.

Natural history of postoperative recurrence of Crohn's disease

After surgical resection of the affected bowel and formation of an ileocolonic anastomosis, recurrence has been observed as early as a few weeks postoperatively [1,10,13,14] . Conversely, patients who undergo an ileostomy and diversion of the fecal stream do not develop recurrence of Crohn's disease. Once bowel continuity is achieved, ulcers develop and Crohn's disease recurs [14,18,19] . Recurrence of Crohn's disease postoperatively starts with aphthous ulcerations in the neoterminal ileum and at the anastomosis with progression to larger ulcers and eventually stricture and fistula formation [12] . This recurrence is thought to be triggered by the presence of intestinal contents and bacteria in the lumen that lead to mucosal invasion by inflammatory cells and lymphocyte activation [1] . The degree of inflammation correlates with the severity of those mucosal lesions and also correlates with clinical recurrence down the line [10,13] .

Postoperative recurrence definitions

Recurrence of Crohn's disease can be defined histologically, endoscopically, radiographically or clinically by the exhibition of symptoms. It is important to note that clinical recurrence tends to lag behind endoscopic/histologic recurrence and most patients have clinically silent disease, yet endoscopically evident inflammation. For this reason, we recommend that all patients undergo an ileocolonoscopy...

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Gale Document Number: GALE|A305150590