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ECCO Guidelines on Therapeutics in Crohn’s Disease: Surgical Treatment
Posted in Lectures on 7 January 2020
Sara Tavares Nogueira, MD
General Surgery Specialist
AIS Channel Medical Team

Crohn’s Disease

Crohn’s disease is a chronic, relapsing inflammatory bowel disease, that can affect the GI tract in all his extension. The most common portion affected is the terminal ileum and proximal colon.
Epidemiologically, Crohn has no specific gender distribution. Onset usually occurs in the 2nd to 4th decade of life, with a smaller peak from the ages of 50 to 60.
Incidence is growing and is higher in developed countries. Prevalence is higher in Europe.
Crohn’s disease is believed to result of a combination of genetic and environmental factors such as intestinal microflora, resulting in abnormal mucosal immune response and epithelial function.
Treatment requires a multidisciplinary team of experts of various of gastroenterologists, surgeons, radiologists, pathologists, infectologists, as well as nutritionists and social workers.

Clinical Presentation, Classification and Diagnosis

Clinical presentation is variable and depends on the level of involvement and the type of disease.
Symptoms can be of 3 distinct types:
1) Gastrointestinal: nausea, vomiting, diarrhea, abdominal pain;
2) Perineal: perianal abscess, complex perianal fistula
3) or Systemic: fever, fatigue, weight loss.
The Montreal classification of IBD was developed in 2005 to accurately classify the phenotype (physical characteristics) of all subtypes of IBD, encompassing disease location (L; L1-4 for CD), behavior (B; B1-B3 for CD), severity (S), and age of onset (A; A1 for diagnosis <17), thus allowing coverage of features at diagnosis and during evolution with time that had not been covered in the previous Vienna classification.
The Paris classification, published in 2011, extended the classification of Crohn’s disease to the pediatric population, which was overlooked in the former ones.

Crohn’s disease diagnosis relies on a combination of symptoms and complementary exams.
Endoscopy, radiology and pathology all contribute to differential and definitive diagnosis. Laboratory tests are not diagnostic, but help guide treatment and evaluate the basal status of the patient.

Management

Management of Crohn’s patients is best achieved in a ultidisciplinary setting, always focusing on the patient, and involves medical and surgical strategies.
Medical therapy is used for symptomatic control and progression blocking. The commonly used agents are corticosteroids, immunosuppressants, anti-TNF agents and the new biological drugs.
Surgery is left for patients with refractory disease or complications.
The ECCO Guidelines, created by the European Crohn’s and Colitis Organisation, are evidence-based guidelines designed to guide professionals in the treatment of patients with Crohn’s disease. The new edition was published in November and is composed of 2 segments: one for Medical treatment and another for Surgical treatment. We will focus on the latter.