Management of Crohn Disease

Abstract

ImportanceCrohn disease, a chronic gastrointestinal inflammatory disease, is increasing in incidence and prevalence in many parts of the world. Uncontrolled inflammation leads to long-term complications, including fibrotic strictures, enteric fistulae, and intestinal neoplasia. Therefore, early and effective control of inflammation is of critical importance.ObservationsThe optimal management approach for Crohn disease incorporates patient risk stratification, patient preference, and clinical factors in therapeutic decision-making. First-line therapy generally consists of steroids for rapid palliation of symptoms during initiation of anti–tumor necrosis factor α therapy. Other treatments may include monoclonal antibodies to IL-12/23 or integrin α4β7, immunomodulators, combination therapies, or surgery. Effective control of inflammation reduces the risk of penetrating complications (such as intra-abdominal abscesses and fistulae), although more than half of patients will develop complications that require surgery. Adverse reactions to therapy include antibody formation and infusion reactions, infections, and cancers associated with immune modulators and biologics and toxicity to the bone marrow and the liver. Both Crohn disease and corticosteroid use are associated with osteoporosis. Vaccinations to prevent infections, such as influenza, pneumonia, and herpes zoster, are important components of health maintenance for patients with Crohn disease, although live vaccines are contraindicated for patients receiving immune suppression therapy.Conclusions and RelevanceThe treatment of patients with Crohn disease depends on disease severity, patient risk stratification, patient preference, and clinical factors, including age of onset and penetrating complications, and includes treatment with steroids, monoclonal antibody therapies, immunomodulators, and surgery. Physicians should be familiar with the advantages and disadvantages of each therapy to best counsel their patients.

The Revival of Surgery in Crohn’s Disease—Early Intestinal Resection as a Reasonable Alternative in Localized Ileitis

“…However, general rates of surgical resection for patients with CD outside the studies mentioned above have remained stable during the last 20 years with 20-35% during the first five years following initial diagnosis [10,21], despite the "aggressive" use of biologicals (step-down approach) [22,23]. In addition, even more powerful therapies such as biologicals initially resulted in increased rates of side effects and reduced quality of life for patients [9,24]. Based on this background but with newer biologicals demonstrating improved safety profiles and treatment efficacy, it is reasonable that quality of life should be chosen as primary end point for (prospective) studies on therapies for patients suffering from CD in the future instead of surgery-free survival.…”

“…Current therapeutic strategies mainly focus on the aberrant reaction within the immune system using anti-inflammatory and immunosuppressive medication. However, despite the introduction of new medical therapies such as biologicals during recent decades, up to 50% of patients treated with immunosuppressants did not show improvement of clinical symptoms while others suffered from mild to severe side effects resulting in reduced quality of life [9,10]. Common side effects include fatigue, arthralgia, recurrent infections, osteoporosis, or cancer (melanoma and lymphoma) [9,11].…”

“…However, despite the introduction of new medical therapies such as biologicals during recent decades, up to 50% of patients treated with immunosuppressants did not show improvement of clinical symptoms while others suffered from mild to severe side effects resulting in reduced quality of life [9,10]. Common side effects include fatigue, arthralgia, recurrent infections, osteoporosis, or cancer (melanoma and lymphoma) [9,11]. Nevertheless, newer biologicals such as vedolizumab or ustekinumab demonstrate significantly lower rates of side effects, are considered as relatively safe treatment options in CD, and show significantly increased therapeutic efficacy [12][13][14].…”

Increased mucin‐degrading bacteria by high protein diet leads to thinner mucus layer and aggravates experimental colitis

“…Inflammatory bowel disease (IBD) is considered to have a multifactorial etiology involving genetic susceptibility, the host immune system, the gut microbiome, and external environmental factors such as smoking and diets. 1,2 At the 21st century, IBD becomes a global disease and has a rapid increasing incidence in countries with westernized diet such as Asia, South America, and Africa. 3 Westernized diet is such a dietary style rich in fat, refined sugar and low in dietary fiber, which is known to be a trigger for IBD.…”

The early phase of Crohn’s disease in a young girl

“…After the procedure, she clinically recovered with intermittent endoscopic surveillance and long-term clinical follow-up evaluation. The early diagnosis and treatment of Crohn's disease, acting as a complex and challenging clinical problem, is of great signifi cance for promoting remission, enhancing therapeutic effect, reducing complications, preventing recurrence and improving quality of life [1,2]. Early diagnosis depends on clinical manifestations, endoscopy, pathology, laboratory, and imaging [3,4].…”