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Crohn’s disease 

Crohn’s disease

Chapter:
Crohn’s disease
Author(s):

Miles Parkes

DOI:
10.1093/med/9780199204854.003.1511_update_002

Update:

Updated information regarding Crohn’s disease pathogenesis, optimization of thiopurine therapy and initiation and cessation of anti-TNF therapy. In particular, evidence for the benefit of combination anti-TNF therapy with thiopurine (from the SONIC study) and criteria for stopping anti-TNF therapy (from the STORI study).

A relevant case history from Oxford Case Histories in Gastroenterology and Hepatology has been added to this chapter.

Updated on 28 Nov 2012. The previous version of this content can be found here.
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date: 30 March 2017

Crohn’s disease is a common form of chronic inflammatory bowel disease. Typically involving the terminal ileum, colon, and perineum, it causes patchy transmural inflammation characterized microscopically by granulomata. Common complications include fibrotic strictures, fistulas, and abscesses.

The trigger is unknown but an unregulated mucosal immune response to commensal bacteria drives the chronic inflammation. Variants in several genes involved in innate immunity are strongly associated, with NOD2, interleukin-23, and autophagy pathways all recently implicated. Smoking also increases the risk.

With a pattern of episodic flares, Crohn’s disease has significant morbidity but low mortality. Treatment of acute inflammatory disease is usually with corticosteroids or therapeutic diets; for steroid-dependence or frequent relapse immunosuppression with azathioprine, 6-mercaptopurine or methotrexate is indicated. Anti-tumour necrosis factor (anti-TNFα‎) antibody therapy can induce rapid remission of aggressive or resistant disease and maintain remission in such cases.

Despite increased use of immunosuppressants 80% of patients require surgery in the long term, most commonly for ileal stricturing. Timely, conservative surgery is the key, minimizing the length of small-bowel resected and using laparoscopic approaches where possible. For colonic disease requiring surgery, segmental colectomy or subtotal colectomy with ileorectal anastomosis are preferred, but significant rectal or perianal involvement may require proctocolectomy and ileostomy.

Perianal Crohn’s disease is treated medically with antibiotics, azathioprine, and anti-TNF antibody therapy; and surgically with abscess drainage and placement of seton sutures through fistulas where possible, rather than more radical options.

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