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Post operative recurrence prevention in Crohn’s disease

Discuss the medical prophylaxis of post operative CD?

  • Following resection and anastomosis, endoscopic signs of recurrence (aphthous and serpiginous ulcers) may be present in 50-80% of patients within 1-3 years of surgery.
  • The post op recurrence rate is much lower in patients with Crohn’s colitis who undergo a total colectomy and ileostomy. Such patients have only a 10 percent recurrence rate in the small intestine at 10 years usually in the bowel immediately above the stoma.
  • Whether the endoscopic findings correlate with clinical course is uncertain. While some studies have found that endoscopic findings predicted symptomatic recurrence others have shown poor correlation between endoscopic and clinical recurrence.
  • Repeat surgery within 10 years is needed in almost 50% of patients after ileocolonic resection and anastomosis.
  • Risk factors for recurrence- smoking, fistulising disease, widespread disease.

Discuss the strategy for preventing post op recurrence?

  • For patients who smoke, cessation significantly reduces postoperative relapse.
  • Additional medical therapy should be considered after surgery, especially if disease has frequently relapsed prior to surgery, or after surgery for fistulating disease, or after a second operation.
  • Azathioprine or mercaptopurine should be considered in patients at high risk of recurrence. These include patients with jejuna or extensive ileo-colonic disease, patients whose initial Crohn’s presentation required surgery, fistulising disease, second resection and smokers
  • Mesalazine (>2 g/day) should be considered in patients with low risk of relapse. It lowers postoperative recurrence in small bowel disease but is ineffective after colonic resection. This regimen should be continued indefinitely. The risk of clinical recurrence may be significantly reduced by 5-ASA maintenance treatment in patients with surgically induced remission. However, the magnitude of the overall effect is small (reduces risk by 13% and NNT is 10). This combined with the excellent safety profile makes it a reasonable choice in low risk patients.

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