This document discusses post-operative Crohn's disease, including indicators for surgery, predictors of recurrence, endoscopic scoring systems like Rutgeerts classification, surveillance methods, biomarkers, predictors of post-operative recurrence, prevention strategies, and treatments. Some key points include that around 75% of Crohn's patients require surgery within 20 years, endoscopic recurrence occurs in up to 90% within 1 year, predictors of recurrence include smoking, penetrating disease, and short disease duration before surgery, and prevention treatments include antibiotics, thiopurines, and anti-TNF therapies.
4. Incidence –
~75% have some surgery by 20 years of diagnosis
Depending on medical culture –
Within 3 years of Δ – 25 – 45 %
Of these 30% - reintervention within 5 yrs
And 1/3rd require 3rd intervention
Cosnes, Gastroenterology, 2011
8. Strictures
Treatment - Surgical/ endoscopic
Study by Scimeca –balloon safe in long term and
long term benefit achieved
Study, n=27, 66.7% responded dilatation
avoided surgery atleast for 7 years
Non responders – surgery needed in 1.6 years
Blomberg, Endoscopy 1991
9. Recurrence of Crohns after
surgery
Upto 90% have endoscopic recurrence with in 1 year
Site – neoterminal ileum, just above the I-C
anastomosis
Of these ~30% manifest at 3 year, 50% at 5 years and
60% at 10 years
Ng SC, Am J Gastro, 2008
Risk of recurrence is perforating disease >
stricturising
Simillis, Am J Gastro, 2008
10. Recurrence can be seen as early as 1 week
post op, bowel continuity predisposes
Progression displays natural history –
Aphthous ulcer stellate
fistula/stricutre
Definition of recurrence – histologically,
endoscopically and clinically.
11. Endoscopic -
Endoscopic score Definition - Rutgeerts classification
i0 No lesion
i1 <5 aphthous lesions
i2 >5 aphthous lesions with N mucosa b/n lesions or skip areas or
lesions confined to I/C anastomosis
i3 Diffuse aphthous ulcers with diffuse inflamed mucosa
i4 Diffuse inflammation with large ulcers, nodules and/or narrowing
Rutgeerts,Gastroenterology 1990
12. Rutgeerts score
Prognosis –
i0/i1 low risk – 80-85% asymptomatic for 3 years
after surgery
Recurrence at 3 years – 5 %
i3/i4 – only 10% asymptomatic after 3 years
Recurrence at 3 yrs - i2, i3 and i4 – 20, 40 and 90%
Blum, Inflam. B D 2009
13. Post operative surviallance
Endoscopy - ileoscopy
Recommended as gold standard by ECCO guidelines
Recommended after 6 -12 months of surgery
Cottone, Gastroenterology, 2006
Capsule (WCE)
Sn and Sp for POR (≥ Rutgeerts i2), 50-79% and 94-
100%
Considered as emerging alternative
Risk impaction in strictures
Bourreille A, Gut, 2006
14. Imaging
USG
Sn and Sp – 77-81% and 86-94%.
Oral contrast enhance USG (SICUS) – Sn – 86%,
Sp – 96% - with BWT cut-off – 5mm
SICUS – as accurate as ileoscopy –but little higher
false positive rate
Useful non invasive tool for initial assesment
Castiglione, IBD, 2008
15. CT scan
CT enterography – most distinguishing features –
Comb sign
Bowel wall thickening
Stratification
Anastomotic stenosis
Sn and Sp – 88% and 97%
ECCO doesnot recommendCT as alternative to
endoscopy – d/t ionising radiation.
Soyer P, Radiology, 2010
16. MRI
Classification of findings
MR -0 – No abnormality
MR 1 – minimal mucosal changes
MR 2 – diffuse aphthoid iletis
MR 3 – Severe recurrence – trans and extramural changes
Compared with Rutgeerts – Kappa value – 0.67
MR & MR3 – Sn & Sp – 89 & 100% for i3 & i4
Emerging non invasive tool, lmtd access and cost
Koilakou, IBD 2010
17. Biomarkers
Fecal calprotectin(FC) and Fecal lactoferrin(FL)
Cut-offs for POR – FC - >50 U, FL.7.5 U(μg/g)
Increase to 2X ULN – disease flare
Both were better than CRP in POR prediction, better sensitivity
But other studies showed ↑ level despite POR
Since they have low specificity, ECCO – does not recommend
their routine use
A Buisson, Digestive and Liver Dis, 2012
18. Predictors of post operative
recurrence
Patient related
Tobacco smoking – OR – 2.5 @ 10y of POR
Female > male
Disease related
Prior surgery
Penetrating and perforating disease
Young age
Shorter duration prior of disease b/f surgery (<10y)
Use of steroids
Multisite disease
Family history
Jana Hashash, Expert Review Gastro-hep, 2012
19. Surgery related
Inconclusive
Surgical margins
Perioperative complications
Need of BTs
Presence and number of granulomas
Type of anastomosis
Least with stappled – end to end anastomosis
Higher with – hand sewn e-to-e.
Yamamoto, Scand J Gastro, 1999
21. Metanalysis (n=1282), 11 RCTs – mesalamine
has only modest, at all benefit in POR
Mesalamine – may have only slight efficacy in
prevention of POR
Jana Hashash, Expert Review Gastro-hep, 2012
Sulphasalazine has no benefit in preventing
POR (Metanalysis)
Ewe, Digestion, 1989
22. Probiotics
Study, using 12 billion Lactobacillus rhamnosus,
(n=45) out come not superior to placebo
Similar results with
Lactobacillus johnsonii
Symbiotics of 4 probiotics and 4 prebiotics
VSL#3
Metanalysis – Pre-pro-biotics not useful
Doherty, Alim Pharmaco , 2010
23. Antibiotics
Rutgeerts – metronidazole – 20mg.kg.d within 7 days of
surgery vs placebo
1 year recurrence – 4% vs 25%
But effect not lasted for 2 and 3 yrs
Rutgeerts,Gastroenterology, 1999
Other study – ornidazole – 1 g/d vs placebo
Recurrence @ 1 yr – 7.9 vs 35% p =0.004
Rutgeerts,Gastroenterology, 2005
Higher side effects – neuropathy in long term Rx, higher
chances of non-complaince
Conclusion – Effective > placebo, but not sustained beyond 1 yr
24. Steroids
RCTs of budesonide vs placebo
N= 129
Duration – 12 months
Response – 52 vs 58%, p>0.05
Steroids don not have any preventive role in
POR prevention
Ewe, Eur J Gastro Hepa, 1999
26. Metanalysis – Modest clinical benefit over
placebo with AZA
15 % more effective than ASA or placebo in
preventing POR – NNT – 7 for 1 year
A Buisson, Digestive and Liver Dis, 2012
Conclusion – Azathioprine and 6-MP had better
recurrence prevention chances than placebo or
ASA but have greater withdrawal rates d/t side
effects
28. A number of studies have proven superiority of
antiTNF therapy over placebo, in endoscopic
and clincal recurrence prevention
Majority of studies did not show any recurrence
with maintenance on antiTNF therapy
These should be considered treatment of choice
in patient with highest risk of recurrence.
29. Treatment
Azathioprine
Studies have shown benefit of AZA over ASA or
placebo, lower rates of endoscopic lesions (30% vs
60%).
Useful in the moderate risk group
Reinisch, Gut, 2010
30. AntiTNF
Significant difference when compared with AZA
or ASA
Most potent drug class to treat POR
A Buisson, Digestive and Liver Dis, 2012
31.
32. Protocol AZA
TPMT –
< 6 – avoidAZA
6-10 – 1.0 mg/kg/d
> 10 – 2.0 mg/kg/d
6-TGN - level, 230 – 260 U in RBCs
– 62% remission rate compared to
36% those with lower
Shunting – 6MMP:6TGN - >10
unlikey to benefit – add allopurinol