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.

1. POST OPERATIVE CROHN’S
DISEASE
ShankarZanwar

2. Surgery in Crohn’s Disease
 Indications
 Intrabdominal abscess
 Medically intractable fistula
 Fibrotic stricture with obstructive symptoms
 Toxic megacolon
 Intractable hemorrhage
 Cancer

3. Predictors of surgery
A Goel, A Dutta, A Chacko, IJG, 2008

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

5. Indian scenario
Sanjay Bandopadhyay, API Med update 2012

6. Sanjay Bandopadhyay, API Med update
2012

7. Mathew Philip, IJG, 2008

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

20. Prevention
 ASA

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

25. Thiopurines – Azathioprine/6-MP

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

27. Anti- TNF therapy

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

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

33. Thank You