1. Disease summary:
Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal (GI) tract that can affect any part from mouth to anus, most commonly involving the terminal ileum and proximal colon. It is characterized by patchy, segmental, transmural inflammation that can lead to complications such as strictures, fistulas, abscesses, and extraintestinal manifestations. The disease results from a complex interplay of genetic susceptibility, environmental factors, immune dysregulation, and alterations in the gut microbiota. Common symptoms include abdominal pain, diarrhea, weight loss, fatigue, and sometimes rectal bleeding. CD has a relapsing-remitting course with periods of flare and remission and can lead to progressive bowel damage and disability if not adequately controlled (PMID: 30485038, 27914655, 38437854).
2. Standard of care:
The management of Crohn's disease aims to induce and maintain remission, prevent complications, improve quality of life, and minimize treatment-related adverse effects. Treatment decisions are guided by disease severity, location, behavior, and patient-specific factors.
Initial Assessment and Diagnosis:
- Diagnosis is confirmed by ileocolonoscopy with biopsy and supported by cross-sectional imaging (MRI, CT enterography) to assess disease extent and complications.
- Laboratory tests include inflammatory markers (CRP), fecal calprotectin, and nutritional assessments.
- Smoking cessation is strongly advised as smoking worsens disease course (PMID: 30485038, 38437854).
Induction of Remission:
- Mild disease may be managed with budesonide or corticosteroids for rapid symptom control.
- Exclusive enteral nutrition (EEN) is an option, especially in pediatric patients, to induce remission without steroids.
- For moderate to severe disease, biologic therapies (anti-TNF agents such as infliximab and adalimumab, anti-integrins like vedolizumab, and anti-interleukin agents such as ustekinumab) are recommended early, particularly in high-risk patients.
- Immunomodulators (thiopurines, methotrexate) may be used as steroid-sparing agents or in combination with biologics.
- Treat-to-target (T2T) strategy is increasingly adopted, aiming for clinical remission, biomarker normalization (e.g., fecal calprotectin), and endoscopic healing to prevent disease progression (PMID: 27914655, 38437854, 30485038).
Maintenance Therapy:
- Continuation of biologics and/or immunomodulators to maintain remission.
- Regular monitoring with clinical assessment, biomarkers, and imaging or endoscopy as needed.
- Avoid prolonged corticosteroid use due to side effects.
Management of Complications:
- Perianal disease requires a multidisciplinary approach combining medical therapy (antibiotics, immunomodulators, biologics) and surgical interventions (abscess drainage, seton placement, fistulotomy).
- Newer therapies such as stem cell therapy and hyperbaric oxygen are emerging for refractory perianal fistulizing disease.
- Surgery is reserved for complications like strictures, fistulas, abscesses, or medically refractory disease but is not curative (PMID: 37207318, 37672347).
Additional Supportive Care:
- Nutritional support and correction of deficiencies.
- Screening and prevention of osteoporosis, anemia, infections, and malignancies.
- Psychological support and management of extraintestinal manifestations.
3. Additional context:
- The treat-to-target approach emphasizes early and tight control of inflammation, adjusting therapy based on objective markers rather than symptoms alone.
- Emerging therapies and personalized medicine approaches are under investigation to improve outcomes.
- Dietary interventions such as the Crohn's Disease Exclusion Diet (CDED) are gaining recognition as adjuncts to medical therapy.
- Multidisciplinary care involving gastroenterologists, surgeons, dietitians, and psychologists is essential for optimal management.
4. References:
- Veauthier B, Hornecker JR. Crohn's Disease: Diagnosis and Management. Am Fam Physician. 2018 Dec 1;98(11):661-669. PMID: 30485038. https://pubmed.ncbi.nlm.nih.gov/30485038/
- Parian AM, Obi M, Fleshner P. Management of Perianal Crohn's Disease. Am J Gastroenterol. 2023 Aug 1;118(8):1449-1461. PMID: 37207318. https://pubmed.ncbi.nlm.nih.gov/37207318/
- Torres J, Mehandru S, Colombel JF. Crohn's disease. Lancet. 2017 Apr 29;389(10080):1741-1755. PMID: 27914655. https://pubmed.ncbi.nlm.nih.gov/27914655/
- Dolinger MT, Torres J, Vermeire S. Crohn's disease. Lancet. 2024 Mar 23; PMID: 38437854. https://pubmed.ncbi.nlm.nih.gov/38437854/
- Singh A, Midha V, Kochhar GS. Management of Perianal Fistulizing Crohn's Disease. Inflamm Bowel Dis. 2024 Sep 3; PMID: 37672347. https://pubmed.ncbi.nlm.nih.gov/37672347/