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Colorectal Crohn disease — Clinical Guidelines

Overview

Colorectal Crohn's disease involves inflammation of the colon and rectum, often presenting with abdominal pain, diarrhea, and complications such as strictures and fistulas. Diagnosis and management require a multidisciplinary approach, including endoscopic evaluation and surgical intervention when necessary. 1 5

Diagnosis

Colonoscopy: Essential for visualizing mucosal lesions and obtaining biopsies.

CT/MRI: Useful for assessing disease extent and complications like fistulas.

Endoscopic Ultrasound (EUS): Can help in evaluating submucosal lesions and fistulas.

Laboratory Tests: Elevated inflammatory markers may support diagnosis but are non-specific.

Symptom-Based Triage: Poor predictor of clinically significant disease; endoscopic confirmation needed. 4

Management

Medical Therapy:

- Anti-TNF Agents: First-line biologic therapy for moderate to severe disease (e.g., infliximab, adalimumab). - Antibiotics: For managing infections, particularly those related to fistulas. - Immunomodulators: Azathioprine or methotrexate for maintenance therapy.

Surgical Intervention:

- Laparoscopic/Minimally Invasive Surgery: Increasingly used for emergencies and resections, offering comparable outcomes to open surgery. 1 5 - Hand-Assisted Laparoscopic Colectomy: Feasible and potentially advantageous in emergency settings. 1

Endoscopic Therapy:

- Endoscopic Submucosal Dissection (ESD): Utilized for localized lesions with conscious sedation (e.g., dexmedetomidine). 9

Special Populations

Pregnancy: Flexible sigmoidoscopy and colonoscopy require careful consideration due to risks of sedation and procedure-related complications; alternatives like MRI may be considered. 14

Pediatrics: Tailored preparation, sedation, and techniques essential for safe colonoscopy in children. 21

Elderly: Increased risk of complications; careful risk-benefit assessment needed for invasive procedures. 1 5

Key Recommendations

Utilize Colonoscopy for Diagnosis and Monitoring: Essential for accurate diagnosis and assessment of disease activity. (Evidence: Strong 4)

Consider Laparoscopic Approaches in Emergency Settings: Laparoscopic or minimally invasive techniques are feasible and comparable to open surgery in outcomes. (Evidence: Moderate 1 5)

Tailor Management Based on Disease Severity: Integrate medical therapy (anti-TNFs, immunomodulators) with surgical intervention as needed, guided by endoscopic findings and clinical response. (Evidence: Moderate 4 5)

Exercise Caution in Pregnant Patients: Opt for non-invasive imaging or carefully managed endoscopic procedures with minimal sedation. (Evidence: Expert opinion 14)

References

1 Lee D, Kang YH, Kim Y, Lee SR, Kim HO, Kim H et al.. Hand-Assisted Laparoscopic Colectomy for Complicated Colorectal Disease in Emergency Settings. JSLS : Journal of the Society of Laparoendoscopic Surgeons 2025. link 2 Swan R, MacVicar E, Carey K, Damaskos D, Ventham N. Outcomes of emergency colorectal surgery within a non-colorectal split site service-a retrospective cohort study. Irish journal of medical science 2025. link 3 Gür HÜ, Koyuncu A. What should we expect when colon wall thickening is detected on abdominal CT scan in the era of artificial intelligence?. Annali italiani di chirurgia 2023. link 4 Ismail MS, Aoko O, Sihag S, Connolly E, Omorogbe J, Semenov S et al.. Lower gastrointestinal symptoms and symptoms-based triaging systems are poor predictors of clinical significant disease on colonoscopy. BMJ open gastroenterology 2020. link 5 Ahmed SE, Jha A, Norman S, Jha M, Garg D. Role and Outcome of Laparoscopic/Minimally Invasive Surgery for Variety of Colorectal Emergencies. Surgical laparoscopy, endoscopy & percutaneous techniques 2020. link 6 Valente M, Silva-Velazco J, Ortega AE. Current Advances in Colorectal Surgery in Latin America: Insights on the 2019 Latin American Association of Coloproctology Congress. Diseases of the colon and rectum 2020. link 7 . Global variation in anastomosis and end colostomy formation following left-sided colorectal resection. BJS open 2019. link 8 Ende AR, De Groen P, Balmadrid BL, Hwang JH, Inadomi J, Wojtera T et al.. Objective Differences in Colonoscopy Technique Between Trainee and Expert Endoscopists Using the Colonoscopy Force Monitor. Digestive diseases and sciences 2018. link 9 Kinugasa H, Higashi R, Miyahara K, Moritou Y, Hirao K, Ogawa T et al.. Dexmedetomidine for conscious sedation with colorectal endoscopic submucosal dissection: a prospective double-blind randomized controlled study. Clinical and translational gastroenterology 2018. link 10 Godber IM, Todd LM, Fraser CG, MacDonald LR, Younes HB. Use of a faecal immunochemical test for haemoglobin can aid in the investigation of patients with lower abdominal symptoms. Clinical chemistry and laboratory medicine 2016. link 11 Jorgensen JE, Elta GH, Stalburg CM, Kolars JC, Stout JM, Korsnes SJ et al.. Do breaks in gastroenterology fellow endoscopy training result in a decrement in competency in colonoscopy?. Gastrointestinal endoscopy 2013. link 12 Brahmania M, Park J, Svarta S, Tong J, Kwok R, Enns R. Incomplete colonoscopy: maximizing completion rates of gastroenterologists. Canadian journal of gastroenterology = Journal canadien de gastroenterologie 2012. link 13 Wexner SD, Denoya P. 19th Annual International Colorectal Disease Symposium. Expert review of gastroenterology & hepatology 2008. link 14 Siddiqui U, Denise Proctor D. Flexible sigmoidoscopy and colonoscopy during pregnancy. Gastrointestinal endoscopy clinics of North America 2006. link 15 Fasih T, Varma JS, Tabaqchali MA. Prospective audit of quality of colonoscopy in a surgical coloproctology unit. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 2004. link80054-4) 16 Mehran A, Jaffe P, Efron J, Vernava A, Liberman MA. Colonoscopy: why are general surgeons being excluded?. Surgical endoscopy 2003. link 17 Leslie A, Steele RJ. Colonoscopy. Journal of the Royal College of Surgeons of Edinburgh 2002. link 18 Hamamoto N, Nakanishi Y, Morimoto N, Inoue H, Tatukawa M, Nakata S et al.. A new water instillation method for colonoscopy without sedation as performed by endoscopists-in-training. Gastrointestinal endoscopy 2002. link 19 Iseli A. Sigmoidoscopy. Is it a general practice procedure?. Australian family physician 1999. link 20 Herold AH, Riker AI, Warner EA, Woodard LJ, Brownlee HJ, Pencev D et al.. Evidence of gender bias in patients undergoing flexible sigmoidoscopy. Cancer detection and prevention 1997. link 21 Wyllie R, Kay MH. Colonoscopy and therapeutic intervention in infants and children. Gastrointestinal endoscopy clinics of North America 1994. link 22 Warhol MJ, Roth J. The ultrastructural labelling of keratin proteins in normal human colonic mucosa by a low temperature embedding, protein A-gold technique. Journal of submicroscopic cytology 1985. link 23 Peranzi G, Lehy T. Endocrine cell populations in the colon and rectum of cat, dog, and monkey: fine structure, immunocytochemistry, and distribution. The Anatomical record 1984. link 24 Nicholls RJ. Sigmoidoscopy. British journal of hospital medicine 1982. link 25 O'Connor JJ. Flexible sigmoidoscopy: is it of value?. The American surgeon 1979. link 26 Hunter AF. Colonoscopy: a new diagnostic and therapeutic technique. The New Zealand medical journal 1976. link 27 Klawon M. Improved cleansing for colonic radiography. Radiologic technology 1976. link

Colorectal Crohn disease