Objective: Provide direction for the management of patients with Crohn’s disease after a bowel resection
Population: Adult patients (> 18 years) with Crohn’s disease with a recent surgical resection
Surgery is often required in up to 80% of Crohn’s disease patients for medically refractory disease or complications such as a bowel obstruction, abscess or fistula. Patients should be stratified based on disease and surgery-related risk factors. Smoking is associated with a higher risk of postoperative disease recurrence; therefore, all patients should receive smoking cessation counselling. All patients should have an ileocolonoscopy 6 to 12 months after surgery to assess for endoscopic recurrence in the neo-terminal ileum. Goals of therapy: Reduce endoscopic and clinical recurrence and maintain disease remission.
Introduction
Although surgery is not curative, it is an important intervention to correct irreversible disease, such as a fibrotic stricture or medically refractory disease.
Clinical remission is often achieved with surgery; however, the majority of patients have postoperative disease recurrence, which is manifested by histologic or endoscopic findings with or without clinical symptoms.
The identification of risk factors for recurrence is important to determine the need for early medical prophylaxis after surgery versus not starting therapy and adopting a clinical monitoring approach.
There is no role for 5-ASA in the prevention of postoperative recurrence.
The algorithm below is a best-practice clinical pathway for the management of patients with Crohn’s disease in clinical remission after surgery.
Management
*Choice of biologic may depend on pre-resection advanced therapy used
The modified Rutgeerts endoscopic scoring system predicts clinical occurrence based on endoscopic findings. The neo-terminal ileum is assessed during initial postoperative endoscopy and scored by the following scale:
| Rutegeerts grade | Endoscopic findings | Decoding |
| i0 | No lesions in the distal ileum | Post-surgery remission |
| i1 | Not more than 5 anastomotic aphthous lesions in the distal ileum | Post-surgery remission |
| i2* | i2a: lesions confined to the ileocolonic anastomosis i2b: > 5 aphthous lesions in neoterminal ileum with or without lesions at the ileocolonic anastomosis | Substantial post-surgery recurrence |
| i3 | Diffuse aphthous ileitis with diffusely inflamed mucosa between the multiple aphthae | Advanced post-surgery recurrence |
| i4 | Diffuse inflammation, with larger lesions: large ulcers and/or nodules/cobble and/or narrowing/stenosis | Advanced post-surgery recurrence |
*No clinical or surgical post-operative difference was observed between the i2a and i2b subcategories. The same treatment can be used for all patients classified under the i2 Rutgeerts category until more prospective studies are available (Rivière, Pauline et al.).
Other Resources
UpToDate® – Patient education: Crohn’s disease (Beyond the Basics) (freely accessible) https://www.uptodate.com/contents/crohn-disease-beyond-the-basics?search=undefined&source=search_result&selectedTitle=1~20&usage_type=default&display_rank=1
American Gastroenterological Association Institute. Managing Crohn’s Disease After Surgery: A Patient Guide. Gastroenterology 2017; 152:296-297 https://doi.org/10.1053/j.gastro.2016.11.039
References
Nguyen GC et al. American Gastroenterological Institute guideline on the management of Crohn’s disease after surgical resection. Gastroenterology 2016; 152:271-275 https://doi.org/10.1053/j.gastro.2016.10.038
Singh, S. and Nguyen GC. Management of Crohn’s Disease after Surgical Resection. Gastroenterology Clinical of North America 2017; 46(3):563-575 https://doi.org/10.1016/j.gtc.2017.05.011
Lamb C et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 1-106 https://doi.org/10.1136/gutjnl-2019-318484
Rivière, Pauline et al. “Comparison of the Risk of Crohn’s Disease Postoperative Recurrence Between Modified Rutgeerts Score i2a and i2b Categories: An Individual Patient Data Meta-analysis.” Journal of Crohn’s & colitis vol. 17,2 (2023): 269-276. https://doi.org/10.1093/ecco-jcc/jjac137