This document provides an overview of the current management of Crohn's disease. It discusses the clinical manifestations and natural history of the disease. Prognostic factors that are associated with progressive disease include young age at diagnosis, extensive initial bowel involvement, and ileal or perianal location. Diagnosis is based on a combination of clinical, endoscopic, imaging and histological findings. Disease activity can be assessed using the Simple Endoscopic Score for Crohn's Disease. Treatment involves risk stratification and either a step-up approach starting with milder treatments or a top-down approach starting with biologics. Anti-TNF agents are recommended for inducing and maintaining remission in moderate to severe Crohn's disease. Sur

1. An Update in the management of
Crohn’s disease
Ahmed Elmoughazy
Assistant lecturer, hepato-gastroenterology unit, Medical research institute, Alexandria University

2. Background
 Crohn’s disease (CD) is an idiopathic
inflammatory bowel disease characterized by
transmural non caseating granulomatous
inflammation.
 Crohn’s disease has an estimated prevalence
140–200 per 100,000.
 The peak incidence is between ages 15 and 25
years, with a smaller second peak between the
fifth and seventh decades.
 The standardized mortality ratio is 1.4 for CD.

3. Clinical manifestation
 Symptoms of CD depend on the anatomical
location of the disease.
 The most common symptom of Crohn’s disease is
chronic diarrhea.
 With ileocecal disease: abdominal pain, diarrhea,
and fever are typical.
 With colonic disease: bloody bowel movements
with diarrhea, weight loss and low-grade fever.
 With gastroduodenal CD: epigastric pain and
early satiety
 With perianal CD: perirectal abscesses, painful
and edematous external hemorrhoids, and anal
and perianal fistulas.

4. Natural history of CD
 The location of Crohn’s disease tends to be stable but can occasionally extend.
 Most patients with Crohn’s disease will present with non-penetrating, non-stricturing disease
behavior, 50% of them will develop an intestinal stricture, abscess, or fistula within 20 years of
diagnosis.
 Only 20–30% of patients with Crohn’s disease will have a non-progressive or course.

5. Prognostic factors
Features that are associated with a high risk for progressive
disease burden include:
1. Young age at diagnosis.
2. Initial extensive bowel involvement.
3. Ileal/ ileocolonic involvement, perianal/severe rectal disease,
and patients presenting with a penetrating or stenosis disease
phenotype .

6. Diagnosis
A single reference standard for the diagnosis of Crohn’s disease [CD] or
ulcerative colitis [UC] does not exist. The diagnosis of CD or UC is based
on a combination of clinical, biochemical, stool, endoscopic, cross-
sectional imaging, and histological investigations

7. Diagnosis
Routine use of serologic markers of IBD to establish the diagnosis of Crohn’s
disease is not indicated.

8. Diagnosis
 Ileocolonoscopy with biopsies from inflamed and uninflamed
segments are required to establish diagnosis except in the case
of acute severe colitis in which sigmoidoscopy may be sufficient.
 The most useful endoscopic features in CD are discontinuous
lesions, presence of strictures and fistulae, and perianal
involvement

9. Diagnosis
Upper GI endoscopy is recommended in patients with CD with
upper GI symptoms, but not for asymptomatic newly diagnosed
adult IBD patients.

10. Diagnosis
All newly diagnosed CD patients should undergo small bowel
assessment [intestinal ultrasound, MR enterography and/or capsule
endoscopy]

11. Phenotypic
classification

12. Simple endoscopic score for Crohn's disease
(SES-CD)

13. Simple endoscopic score for Crohn's disease
(SES-CD)

14. Simple endoscopic score for Crohn's disease (SES-CD)

0-149 points: Asymptomatic remission
150-220 points: Mildly to moderately active Crohn's disease
221-450 points: Moderately to severely active Crohn's disease
451-1100 points: Severely active to fulminant disease

15. Comprehensive assessment
CBC, electrolytes, liver enzymes, and a stool sample for microbiological
analysis, including C. difficile.
CRP>>> The presence of raised inflammatory markers [CRP] broadly
correlates with clinical severity in CD.
Calprotectin values correlate well with endoscopic indices of disease
activity and are thus important in various clinical settings, including
initial diagnosis, diagnosis of relapse, and response to treatment.

16. Comprehensive assessment
Malnutrition, or
malabsorption.
Assess for Fe
deficiency Anemia
Immunisation
status.
Consider
screening for
latent
tuberculosis.

17. Monitoring
 Clinical and biochemical response to treatment of Crohn’s disease [CD] should be determined
within 12 weeks following initiation of therapy.
 Endoscopic or transmural response to therapy should be evaluated within 6 months following
initiation of therapy.
 In patients with IBD who have reached clinical and biochemical remission, monitoring is aimed at
early recognition of a disease flare. The interval of monitoring should be between 3 to 6 months.

19. J Crohns Colitis, Volume 13, Issue 2, February 2019, Pages 144–164K, https://doi.org/10.1093/ecco-jcc/jjy113
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Figure 1. Targets along the disease progression pathway in IBD.

20. Risk stratification

21. Step up vs Top down

23. 5-aminosalicylates or sulfasalazine are not recommended either to induce or
maintain remission in moderate to severe CD

24. Anti-TNF

25. Anti-TNF

26. Anti-TNF

28. Surgery