Inflammatory Bowel Disease Clinical Practice Guidelines (2019)

British Society of Gastroenterology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 04, 2019

Crohn Disease

Diagnosis

Diagnostic procedures for suspected Crohn disease include ileocolonoscopy with segmental colonic and ileal biopsies, to investigate for microscopic disease, and imaging to assess the location and extent of small bowel disease.

Conventional barium fluoroscopic and nuclear medicine techniques have largely been replaced by cross-sectional imaging (ie, MRI, CT, and ultrasonography). The latter techniques have the advantage of evaluating both luminal and extraluminal disease. To avoid exposing the patient to ionizing radiation, an emphasis should be placed on magnetic resonance enterography and ultrasonography.

Capsule endoscopy may provide better sensitivity for mucosal small bowel Crohn disease compared with radiological imaging techniques, and, generally, capsule endoscopy can be performed in situations in which inflammatory small bowel disease is still suspected despite normal or equivocal cross-sectional imaging findings.

Treatment

For remission-induction treatment for mild-to-moderate ileocecal Crohn disease, the recommended therapy is ileal-release budesonide at 9 mg once daily for 8 weeks.

For remission-induction treatment for mild-to-moderate Crohn colitis, the recommended therapy is an 8-week course of systemic corticosteroids.

The suggested surgical treatment for localized ileocecal Crohn disease in patients (1) in whom initial medical therapy failed, (2) who relapsed after initial medical therapy, or (3) who prefer surgery over continued medical treatment is laparoscopic resection.

For moderate-to-severe uncomplicated luminal ileocolonic Crohn disease, the recommended treatment is systemic corticosteroids initially, but if patients have extensive disease or other poor prognostic features, consideration should be given to early introduction of biological therapy.

Avoid systemic or locally acting corticosteroids for maintenance treatment in ileocolonic Crohn disease, owing to toxicity and lack of efficacy.

For moderate-to-severe Crohn disease that is responsive to prednisolone, consider early introduction of maintenance therapy with thiopurines or methotrexate in order to minimize the risk of disease flare when prednisolone is withdrawn.

Mesalazine is not recommended for induction or maintenance of remission in Crohn disease.

Biologic therapy is recommended in patients with disease refractory to immunomodulator therapy despite dose optimization. Considerations in the drug choice (ie, anti–tumor necrosis factor therapy, ustekinumab, vedolizumab) include patient preference, cost, likelihood of adherence, safety data, and response speed to the drug.

Leucocyte apheresis should not be used for active Crohn disease, owing to lack of efficacy.

Perianal Crohn disease

The recommend procedure for assessment of perianal disease is pelvic MRI; it is an important adjunct to the clinical assessment and examination under anesthesia for evaluating the possibility of fistulizing perianal Crohn disease. Endoanal ultrasonography may also be used depending on local availability and expertise.

Setons should be placed in order to prevent reaccumulation of perianal sepsis in fistulizing Crohn disease.

Post surgery, the recommended first-line biological treatment for complex perianal fistulas is infliximab; this should be started immediately upon achieving adequate drainage of sepsis.

Owing to poor long-term results, particularly for patients with complex disease and/or ongoing disease activity, surgical options for perianal Crohn disease fistulas (eg, advancement flap, ligation of intersphincteric fistula tract, infill procedures) should only be offered to selected patients after counseling.

Postsurgical management of Crohn disease

If patients have recurrent symptoms after surgical resection for Crohn disease but no evidence of active inflammation, consider alternate diagnoses, including bacterial overgrowth, adhesions, bile salt malabsorption, functional bowel disorders, or fibrostenotic or anastomotic strictures.

Actively encourage all patients to quit smoking after intestinal resection for Crohn disease.

Mesalazine is not recommended to prevent recurrence after ileocolonic Crohn disease resection.

For more information go to Inflammatory Bowel Disease, Crohn Disease, and Ulcerative Colitis.

For more Clinical Practice Guidelines, go to Guidelines.

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