Management of active Crohn disease

Abstract

Importance: Treatment of Crohn disease is rapidly evolving, with the induction of novel biologic therapies and newer, often more intensive treatment approaches. Knowing how to treat individual patients in this quickly changing milieu can be a challenge.

Objective: To review the diagnosis and management of moderate to severe Crohn disease, with a focus on newer treatments and goals of care.

Evidence review: MEDLINE was searched from 2000 to 2011. Additional citations were procured from references of select research and review articles. Evidence was graded using the American Heart Association level-of-evidence guidelines.

Results: Although mesalamines are still often used to treat Crohn disease, the evidence for their efficacy is lacking. Corticosteroids can be effectively used to induce remission in moderate to severe Crohn disease, but they do not maintain remission. The mainstays of treatment are immunomodulators and biologics, particularly anti-tumor necrosis factor.

Conclusion and relevance: Immunomodulators and biologics are now the preferred treatment options for Crohn disease.

Conflict of interest statement

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Cheifetz reports participation in advisory boards for UCB, Janssen (previously Centocor), Abbott, Warner-Chillcot (previously Procter & Gamble), Shire, Given Imaging, and Prometheus. He reports research support from Pfizer and the National Institute of Diabetes and Digestive and Kidney Diseases (grant 1R01DK092235-01A1).

Figures

Figure 1. Differences in Disease Characteristics Between Crohn Disease and Ulcerative Colitis

Figure 2. Helical Computed Tomography Imaging of the Patient's Abdomen and Pelvis

Coronal computed tomography views show slightly increased enhancement in the mucosa of the terminal ileum near the ileocecal valve with areas of slight wall thickening and mural stratification with predominantly intramural fat (yellow arrowheads), as well as feculent luminal contents (pink arrowhead). More proximal loops of ileum are slightly dilated (blue arrowheads).

Figure 3. Biopsy of the Patient's Ileal Mucosa

Biopsy demonstrating replacement of the normal intestinal-type epithelium, composed of goblet cells and enterocytes, with mucous-type glands normally seen in the gastric pylorus (hematoxylin-eosin stain, original magnification ×400). This histologic feature of pyloric gland metaplasia is indicative of chronic injury often seen in the terminal ileum of patients with Crohn disease.