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Crohn's disease

What's new

Updated 2024 AGA guidelines on diet and nutritional therapy in Crohn's disease.

Background

Overview

Definition
CD is a chronic relapsing IBD characterized by a transmural granulomatous inflammation most commonly affecting the ileum, colon, or both.
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Pathophysiology
The exact cause of CD is unknown; however, a complex interplay of genetic factors, environmental factors, immune dysregulation to intestinal microbiota have been implicated.
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Disease course
The complex interplay of genetic, environmental factors and immune dysregulation to intestinal microbiota result in CD, which causes clinical manifestations of chronic diarrhea, fatigue, abdominal pain, weight loss, bloody stools, mucinous stools, peripheral arthritis, aphthous stomatitis, uveitis, erythema nodosum, ankylosing spondylitis, pyoderma, gangrenosum, psoriasis, PSC. Disease progression may lead to fistulae and decreased QoL.
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Prognosis and risk of recurrence
The annual mortality rate in CD is 1.6%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of Crohn's disease are prepared by our editorial team based on guidelines from the American Gastroenterological Association (AGA 2024,2023,2021,2020,2018,2017,2013), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2024), the European Society for Clinical Nutrition and Metabolism (ESPEN 2023), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN 2023), the ...
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Screening and diagnosis

Clinical presentation
As per ACG 2018 guidelines:
Recognize that hallmark/cardinal symptoms of CD include abdominal pain, diarrhea, and fatigue; weight loss, fever, growth failure, anemia, recurrent fistulas, or extraintestinal manifestations can also be presenting features.
E
Recognize that extraintestinal manifestations of CD include:
seronegative arthritis (both axial and peripheral)
dermatological pathology (including pyoderma gangrenosum and erythema nodosum)
ocular pathology (including uveitis, scleritis, and episcleritis)
hepatobiliary disease (PSC)
thromboembolic complications (both venous and arterial)
bone disease (osteoporosis, osteonecrosis)
cholelithiasis and nephrolithiasis
immune-mediated diseases (asthma, chronic bronchitis, pericarditis, psoriasis, celiac disease, rheumatoid arthritis, and multiple sclerosis). (Summary statement)
E
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  • Natural history

  • Diagnosis

Diagnostic investigations

Routine blood tests
As per ACG 2018 guidelines:
Obtain laboratory investigations for inflammation, anemia, dehydration, and malnutrition as part of the initial evaluation of patients with CD.
E
Do not obtain serologic markers of IBD routinely to establish the diagnosis of CD.
D

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  • Stool tests (fecal calprotectin)

  • Stool tests (fecal pathogens)

  • Emergency laboratory workup

  • Genetic testing

  • Diagnostic imaging (general approach)

  • Diagnostic imaging (perianal disease)

  • Diagnostic imaging (complications)

  • Evaluation of anemia

  • Screening for osteoporosis

  • Screening for depression and anxiety

Diagnostic procedures

Lower gastrointestinal endoscopy and biopsy
As per ESGE 2023 guidelines:
Perform ileocolonoscopy as the first endoscopic examination in patients with suspected CD.
A
Perform device-assisted enteroscopy with small-bowel biopsies in patients with noncontributory ileocolonoscopy and suspected CD on small-bowel cross-sectional imaging or small-bowel capsule endoscopy.
A

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  • Upper gastrointestinal endoscopy

  • Video capsule endoscopy (indications)

  • Video capsule endoscopy (preparation)

  • Video capsule endoscopy (capsule retention)

Medical management

Induction of remission, mild-to-moderate disease, 5-ASAs: as per ECCO 2020 guidelines, avoid using 5-aminosalicylic acid for induction of remission in patients with CD.
D

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  • Induction of remission, mild-to-moderate disease (corticosteroids)

  • Induction of remission, mild-to-moderate disease (antibiotics)

  • Induction of remission, moderate-to-severe disease (5-ASAs)

  • Induction of remission, moderate-to-severe disease (corticosteroids)

  • Induction of remission, moderate-to-severe disease (other immunosuppressants)

  • Induction of remission, moderate-to-severe disease (thiopurines)

  • Induction of remission, moderate-to-severe disease (anti-TNFs)

  • Induction of remission, moderate-to-severe disease (other biologics)

  • Maintenance therapy, medically induced remission (thiopurines)

  • Maintenance therapy, medically induced remission (methotrexate)

  • Maintenance therapy, medically induced remission (anti-TNFs)

  • Maintenance therapy, medically induced remission (other biologics)

  • Maintenance therapy, medically induced remission (5-ASAs)

  • Maintenance therapy, medically induced remission (corticosteroids)

  • Maintenance therapy, medically induced remission (antibiotics)

  • Maintenance therapy, surgically induced remission

  • Symptomatic therapy

  • Management of acute abdomen

  • Management of intra-abdominal abscesses (antibiotics and drainage)

  • Management of intra-abdominal abscesses (anti-inflammatory therapy)

  • Management of anemia (iron supplementation)

  • Management of anemia (RBC transfusion)

  • Management of anemia (monitoring of recurrence)

  • Management of anemia (management of recurrence)

  • Management of anemia (management of non-IDA anemia)

Inpatient care

Thromboprophylaxis: as per AAST/WSES 2021 guidelines, administer VTE prophylaxis with LMWH as soon as possible in the emergency setting for the high risk of thrombotic events related to complicated IBD.
A

Nonpharmacologic interventions

Smoking cessation: as per ACG 2018 guidelines, advise patients with CD to quit smoking as it exacerbates disease activity and accelerates disease recurrence. Encourage active smoking cessation programs.
B

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  • Physical activity

  • Dietary modifications

  • Nutritional support (counseling)

  • Nutritional support (general principles)

  • Nutritional support (exclusion diet)

  • Nutritional support (oral nutritional supplements)

  • Nutritional support (enteral nutrition)

  • Nutritional support (parenteral nutrition)

  • Nutritional support (energy requirements)

  • Nutritional support (protein requirements)

  • Nutritional support (micronutrient requirements)

  • Nutritional support (vitamin supplements)

  • Nutritional support (management of malnutrition)

  • Nutritional support (avoidance of dehydration)

  • Nutritional support (avoidance of refeeding syndrome)

  • Probiotics

Therapeutic procedures

Fecal microbiota transplantation: as per AGA 2024 guidelines, avoid offering conventional fecal microbiota transplantation in adult patients with CD outside of clinical trials.
D

Perioperative care

Preoperative medications
As per AAST/WSES 2021 guidelines:
Wean off corticosteroids (preoperatively, ideally 4 weeks) and stop anti-TNFs before surgery, as soon as possible to decrease the risk of postoperative complications, in accordance with a gastroenterologist.
B
Recognize that preoperative anti-TNFs and corticosteroids are risk factors for intra-abdominal sepsis in patients requiring emergency resectional surgery.
B

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  • Perioperative nutrition

  • Preoperative smoking cessation

  • Preoperative bowel preparation

Surgical interventions

Indications for surgery, refractory disease
As per AAST/WSES 2021 guidelines:
Perform surgical exploration by laparotomy in hemodynamically unstable patients with severe colitis not responding to medical treatment, taking into consideration damage control surgery principles with or without an open abdomen.
B
Perform subtotal colectomy with ileostomy in patients presenting with acute severe refractory colitis, and massive colorectal bleeding not responding to medical treatment, in a laparoscopic or open approach according to patient's hemodynamic stability and surgeon's skills.
B

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  • Indications for surgery (hemorrhage)

  • Indications for surgery (perforation)

  • Indications for surgery (strictures)

  • Indications for surgery (toxic megacolon)

  • Indications for surgery (abdominal abscess)

  • Indications for surgery (anorectal abscess)

  • Indications for surgery (enteric fistulas)

  • Indications for surgery (carcinoma or dysplasia)

  • Choice of surgical intervention

Specific circumstances

Pediatric patients, nutritional therapy
As per ECCO/ESPGHAN 2020 guidelines:
Offer dietary therapy with exclusive enteral nutrition as first-line therapy for induction of remission in pediatric patients with active luminal CD.
B
Offer monotherapy with maintenance enteral nutrition (at least 50% of daily energy requirements) to prolong remission in pediatric patients with low-risk CD reached clinical remission.
B

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  • Pediatric patients (induction of remission, corticosteroids)

  • Pediatric patients (induction of remission, TNF inhibitors)

  • Pediatric patients (induction of remission, monoclonal antibodies)

  • Pediatric patients (maintenance of remission, DMARD)

  • Pediatric patients (maintenance of remission, TNF inhibitors)

  • Pediatric patients (maintenance of remission, monoclonal antibodies)

  • Pediatric patients (therapies to avoid)

  • Pediatric patients (monitoring of treatment response)

  • Pregnant patients (nutritional support)

  • Pregnant patients (surgical management)

  • Elderly patients

  • Patients with obesity (evaluation)

  • Patients with obesity (nutrition)

  • Patients with obesity (weight loss)

  • Patients with obesity (anti-obesity medications)

  • Patients with obesity (bariatric surgery)

  • Patients with TPMT deficiency (adjustment of azathioprine)

  • Patients with TPMT deficiency (adjustment of 6-mercaptopurine)

  • Patients with fistulizing disease (anti-TNFs)

  • Patients with fistulizing disease (other biologics)

  • Patients with fistulizing disease (thiopurines)

  • Patients with fistulizing disease (tacrolimus)

  • Patients with fistulizing disease (antibiotics)

  • Patients with fistulizing disease (stem cell therapy)

  • Patients with fistulizing disease (seton placement)

  • Patients with fistulizing disease (fibrin glue injection)

  • Patients with fistulizing disease (anal fistula plug)

  • Patients with fistulizing disease (abscess drainage)

  • Patients with fistulizing disease (surgical management)

  • Patients with fistulizing disease (nutritional support)

  • Patients with enterocutaneous fistula (nutritional assessment)

  • Patients with enterocutaneous fistula (medical therapy)

  • Patients with enterocutaneous fistula (surgical management)

  • Patients with ostomy

  • Patients with pouchitis

  • Patients with C. difficile infection (antibiotic therapy)

  • Patients with C. difficile infection (withholding immunosuppressive therapy)

  • Patients with C. difficile infection (fecal microbiota transplantation)

Preventative measures

Healthy diet: as per AGA 2024 guidelines, recognize that a healthy, balanced, Mediterranean diet rich in a variety of fruits and vegetables and decreased intake of ultra-processed foods are associated with a lower risk of developing IBD.
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  • Breastfeeding

  • Routine immunizations

Follow-up and surveillance

Therapeutic drug monitoring
As per ECCO 2020 guidelines:
Insufficient evidence to recommend for or against proactive therapeutic drug monitoring in patients with CD in clinical remission under anti-TNF treatment.
I
Insufficient evidence to recommend for or against reactive therapeutic drug monitoring in patients with CD lost response to an anti-TNF agent.
I

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  • Postoperative imaging (early)

  • Postoperative imaging (late)

  • Serial laboratory assessment

  • Serial endoscopic assessment (ileocolonscopy)

  • Serial endoscopic assessment (video capsule endoscopy)

  • Serial imaging assessment

  • Cervical cancer surveillance

  • Skin cancer surveillance

Quality improvement

Documentation: as per ACG 2018 guidelines, document the type of IBD in the medical record, along with the location and level of activity.
E