Managing ‘silent’ postoperative Crohn’s disease
ORLANDO — Surgery is big step in the management of Crohn’s disease, but it is not the last step. In many patients the disease will persist, and their physicians must develop a plan to identify and address any issues that arise.
In a presentation at Advances in Inflammatory Bowel Disease, Miguel Regueiro, MD, chair of the department of gastroenterology, hepatology and nutrition at Cleveland Clinic, discussed the management of postoperative CD and what the road ahead looks like in 2020 and beyond.
“Crohn's disease after surgery is silent, so patients don't feel the symptoms even when you see it coming back,” Regueiro told Healio Gastroenterology and Liver Disease. “We need to monitor these patients because their symptoms will not tell us when they are having disease.”
The first step in managing CD after surgery is to be proactive before the patients goes under the knife. That means recognizing that IBD, in general, is a multi-disciplinary disease, with GI and surgery at the core.
“All of my clinics are with colorectal surgeons in the same clinic,” Regueiro said. “I think it's important that we work together, especially around postoperative and what I would say is peri-operative Crohn's.”
This multidisciplinary team works with patients and follows up after surgery to ensure they get the care they need.
Part of that care is recognizing that recurrence is common after surgery, particularly among patients with certain risk factors. Regueiro said those patients most likely need to be on a biologic after surgery and need to be monitored for recurrence with a colonoscopy 6 months after surgery.
Regueiro also said that things are beginning to shift, including how IBD doctors view the microbiome and how it might help identify patients at higher risk for recurrence.
“I presented some data looking at microbiome in the post-op setting, and we might be learning that there are differences in the bacteria in the gut that makes somebody high likelihood of getting Crohn's in the future recurrence vs. those that aren't,” he said.
Finally, Regueiro focused on another important category of patients, those who experience recurrence at the anastomosis.
“For years we thought that was azotemia, lack of blood supply just because of the surgery,” he said. “Now we are realizing that's probably Crohn's. ... Rather than say that they are good for 5 more years, you're coming back 6 months to a year, and we're doing another colonoscopy. We're following them more closely because it is Crohn's disease.”
Although some research has suggested that these patients need different medical management, Regueiro said he is not quite there yet.
“But we need to monitor them more closely,” he said. – by Alex Young
Regueiro M. et al. 2020 Management of Post-Operative CD: The Road Ahead. Presented at: Advances in Inflammatory Bowel Disease; Dec. 12-14, 2019; Orlando.
Disclosures: Regueiro reports financial relationships with AbbVie, Amgen, Celgene, Janssen, Miraca Labs, Pfizer, Salix, Shire, Takeda and UCB.