Crohn's disease is a chronic inflammatory condition that affects the gastrointestinal tract and often causes extraintestinal manifestations. Diarrhea, abdominal pain, fatigue, weight loss, and fever are common symptoms. Children may present with changes in growth velocity or delayed puberty. Initial evaluation for suspected Crohn's disease includes endoscopy and cross-sectional imaging. Fecal calprotectin testing is useful for determining whether ileocolonoscopy and imaging are needed in uncertain cases. These tests are critical in monitoring treatment effectiveness because mucosal inflammation may remain after symptoms resolve and inflammatory markers normalize. Patients should be tested for iron, 25-hydroxyvitamin D, folate, and vitamin B12 deficiencies. Frequent screening for colon cancer is indicated due to increased colon cancer risk. Most guidelines recommend colonoscopy 8 years after symptom onset, with monitoring dependent on additional risk factors. Treatment is based on disease severity and whether remission is being induced or maintained. Budesonide, sulfasalazine, and dietary modifications should be used to induce remission in mild to moderate disease. Corticosteroids and biologic therapy, with or without immunomodulators, may be used to induce remission of moderate to severe disease. Severe disease is initially treated with intravenous corticosteroids or anti–tumor necrosis factor agents. Perianal and fistulizing disease require treatment of infection, followed by advanced medical therapy and surgical repair.
Crohn's disease is a chronic inflammatory condition affecting the gastrointestinal tract from mouth to anus. It often causes extraintestinal manifestations and transmural inflammation and includes skip lesions, whereas ulcerative colitis is typically limited to the colon and causes mucosal and submucosal inflammation with continuous lesions proximally from the rectum.1,2 The estimated prevalence of Crohn's disease is 305 per 100,000 (ie, approximately 1 million people in the United States).3 Incidence is highest in people 10 to 29 years of age and gradually decreases with advancing age.3 The mortality rate is 1.4 times higher than the general population.4 Morbidity is common, with 30% of people who have Crohn's disease requiring surgery within 10 years of diagnosis and 80% eventually requiring hospitalization.4 One-third of patients have fistulas, typically perianal but also rectovaginal, enterovesical, and enteroenteric.4 Intra-abdominal abscess, intestinal strictures, and bowel perforations can occur. Other complications include increased rates of cancer, depression, anxiety, arthropathies, skin abnormalities, eye disease, hepatobiliary disease, nephrolithiasis, bone fractures, and thromboembolic events.2,4
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Evaluate for Crohn's disease in children with abdominal symptoms and growth faltering.9,10 | C | Systematic review of observational studies |
| Consider testing stool for fecal calprotectin to determine whether ileocolonoscopy and imaging are needed in patients with gastrointestinal symptoms less likely to be Crohn's disease.19–21,30 | C | Retrospective cohort study and systematic reviews of observational studies with disease-oriented outcomes |
| Counsel patients who smoke and offer interventions for cessation to reduce the risk of hospitalization, surgery, postoperative recurrence, peripheral joint arthritis, and more penetrating disease. Smoking cessation reduces the number of flares and need for corticosteroids and immunomodulators.4,32,33 | B | Consensus guidelines based on observational studies and systematic review of observational studies |
| Systemic corticosteroids should be discontinued after 3 months in patients with Crohn's disease.4,42 | B | Consensus guidelines based on meta-analysis |
| Transfer patients without bowel perforation who require abdominal surgery to a high-volume, specialized facility to reduce postoperative complications; treat malnutrition and taper corticosteroids before surgery to improve outcomes.49 | C | Consensus guidelines based on observational studies |
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
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