Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are ...preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.
The treatment of inflammatory bowel disease (IBD)—ulcerative colitis (UC) and Crohn’s disease (CD)—has evolved beyond surgery with the introduction of biologic agents, primarily antibodies against ...mediators of inflammation and cell attraction. Anti-tumor necrosis factor (TNF) agents have been the first line treatment for moderate to severe ulcerative colitis and Crohn’s disease for more than 15 years. During that time much has been learnt about how best to use these agents. This review will assess the evidence on how to optimize the use of anti-TNF agents; when and how to start treatment; how to monitor treatment and when to de-escalate it; and the potential adverse effects of these drugs. New and emerging treatments such as anti-attractants, anti-interleukins, and Janus kinase (JAK) inhibitors will also be discussed.
Guidelines for clinical practice are intended to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo-controlled studies are ...preferable, but compassionate use reports and expert review articles are utilized in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject without regard to the specialty training or interests and are intended to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. Each has been extensively reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision of analysis. The recommendations of each guideline are therefore considered valid at the time of their production based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at the publication in order to assure continued validity.
In the management of Crohn's disease, earlier aggressive treatment is becoming accepted as a strategy to prevent or retard progression to irreversible bowel damage. It is not yet clear, however, if ...this same concept should be applied to ulcerative colitis. Hence, we review herein the long‐term structural and functional consequences of this latter disease. Disease progression in ulcerative colitis takes six principal forms: proximal extension, stricturing, pseudopolyposis, dysmotility, anorectal dysfunction, and impaired permeability. The precise incidence of these complications and the ability of earlier, more aggressive treatment to prevent them have yet to be determined. (Inflamm Bowel Dis 2011;)
Purpose of Review
Not all injuries of the terminal ileum are Crohn’s disease. It is the purpose of this review to consider the differential diagnosis of other acute and chronic ileal lesions.
Recent ...Findings
The recognition of a granulomatous disease of the terminal ileum, distinct from tuberculosis, dates back over 85 years and perhaps much farther, but over the past decades, many other clinical pathologic entities have been described that are neither tuberculosis nor Crohn’s eponymous regional enteritis. In recent years, the catalog of lesions mimicking Crohn’s disease of the small bowel and proposals for differential diagnosis and treatment have expanded to include newly reported appendiceal pathology, primary cancers and lymphomas of the intestine, unexpected metastases from distant organs, unusual infections, vasculitides and other ischemic conditions, Behçet’s disease, endometriosis, and drug reactions.
Summary
A diagnosis of Crohn’s disease should not be a reflex action in the face of small bowel structural or inflammatory lesions without consideration of pathology in adjacent organs, primary and metastatic lesions of the small intestine, infections, vascular diseases, infiltrative diseases, drug injury, or other “idiopathic” conditions.
Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available ...literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.
10.1093/ibd/izx108_video1
izx108_Video
5754037501001
Introduction
Crohn’s disease (CD) follows a relapsing and remitting course incurring cumulative bowel damage over time. The question of whether or not the timing of the initiating biologic therapy ...affects long-term disease progression remains unanswered. Herein, we calculated rates of change in the Lémann index—which quantifies accumulated bowel damage—as a function of the time between the disease onset and initiation of biologic therapy. We aimed to explore the impact of the earlier introduction of biologics on the rate of progression of long-term cumulative bowel damage.
Methods
Medical records of CD patients treated during 2009–2014 at The Mount Sinai Hospital were queried. Inclusion criteria were two comprehensive assessments allowing calculation of the index at
t
1
and
t
2
: two time-points ≥ 1 year apart. Patients with biologics introduced before or within 3 months at inclusion (
t
1
) were defined as Bio-pre-
t
1
and those who did not as Bio-post-
t
1
. The rate of disease progression was calculated as the change in the index per year during
t
1
–
t
2
.
Results
A total of 88 patients were studied: 58 Bio-pre-
t
1
and 30 Bio-post-
t
1
. Among the 58 Bio-pre-
t
1
cases, damage progressed in 29 (50%), regressed in 20 (34.5%), and stabilized in 9 (15.5%). Median time to initiation of biologics among patients whose index improved was nominally shorter compared to that in patients whose index progressed (8 vs. 15 years). Earlier introduction of biologics tended to correlate with the slower rate of progression (
ρ
= 0.241;
p
= 0.069).
Conclusions
Earlier introduction of biologics tended to correlate with the slower progression of bowel damage in CD, reflected by the reduced rate of Lémann index progression.
To be sure, the advent of infliximab (IFX) and other biologic agents, as well as janus kinase inhibitor, has brought about revolutionary advances in the treatment of IBD. ...the etiologies of Crohn's ...disease (CD) and ulcerative colitis (UC) have not yet been clarified, the incidence of IBD in the world is increasing, and reliance on biologic therapy has been tempered somewhat by the recognition that the maintenance of remissions induced by these new agents—especially antitumor necrosis factors—is limited. ...in anticipation of a controlled trial, our attention focused on CD because there was fear of immunosuppressives predisposing to colon cancer in UC but not yet recognized for CD.
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