Principal changes with respect to the 2004 ECCO guidelines 

Ileocolonoscopy is recommended within the first year after surgery where treatment decisions may be affected (Statement 8C).

Thiopurines are more effective than mesalazine or imidazole antibiotics alone in post-operative prophylaxis (Statement 8F).

### 8.1 Epidemiology of post-operative Crohn's disease

In the natural history of CD, intestinal resection is almost unavoidable since about 80% of patients require surgery at some stage. Surgery is unfortunately not curative as the disease inexorably recurs in many patients. The post-operative recurrence rate varies according to the definition used: clinical, endoscopic, radiological, or surgical. It is lowest when the repeat resection rate is considered, intermediate when clinical indices are used and highest when endoscopy is employed as the diagnostic tool.1–10

Data from endoscopic follow-up of patients after resection of ileo-caecal disease have shown that in the absence of treatment, the post-operative recurrence rate is around 65–90% within 12 months and 80–100% within 3 years of the operation. The clinical recurrence without therapy is about 20–25%/year.1,10 It has been demonstrated that the post-operative clinical course of CD is best predicted by the severity of endoscopic lesions. Symptoms, in fact, appear only when severe lesions are present and it is not uncommon to observe patients with fairly advanced recurrent lesions at endoscopy who remain asymptomatic.1 For these reasons, clinical indices such as the CDAI have low sensitivity at discriminating between patients with or without post-operative recurrence.11

These data mandate strategies aimed at interrupting or delaying the natural course of post-operative recurrence. Several medications have been tried in an attempt to prevent post-operative recurrence, mostly with disappointing results. The aim of this Consensus was therefore critically to evaluate the optimal strategies for the management of post-operative recurrence in CD. Most, if not all, of the evidence available deals with …

/pdf/the-second-european-evidence-based-consensus-on-the-430j75rc37.pdf

The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations

AGA technical review on perianal Crohn's disease.

https://www.gastrojournal.org/article/S0016-5085(01)36224-8/pdf

A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn's perianal fistulas

This third section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn's disease.

https://gut.bmj.com/content/gutjnl/55/suppl_1/i36.full.pdf

European evidence based consensus on the diagnosis and management of Crohn's disease: special situations.

https://www.gastrojournal.org/article/S0016-5085(07)01642-3/pdf

Diagnostics of Inflammatory Bowel Disease

To investigate the potential of MR imaging in the evaluation of sinus tracts or fistulae associated with Crohn disease, 17 patients with pelvic or abdominal fistulae or sinus tracts underwent MR imaging with multislice spin-echo techniques, 500/15 and 1600/22,80 (TR/TE). The presence of fistulae and/or sinus tracts was confirmed by contrast-enhanced CT (n = 17) and/or sonography (n = 8), sinography (n = 6), or barium studies (n = 4). In all but three cases the fistulae and extramucosal inflammatory abnormalities were shown by MR. T1-weighted images provided excellent delineation of the extension of the fistulae relative to sphincters and adjacent hollow viscera and showed inflammatory changes in fat planes. T2-weighted images showed fluid collections within the fistulae, localized fluid collections in extraintestinal tissues, and inflammatory changes within muscles. The supralevator and infralevator compartments were well defined on coronal images. Thus, the perirectal spread of fistulae and sinus tracts ...

https://www.ajronline.org/doi/pdfplus/10.2214/ajr.152.5.999

Diagnosis of fistulae and sinus tracts in patients with Crohn disease: value of MR imaging

Fifty-seven patients with palpably enlarged peripheral lymph nodes underwent detailed ultrasonographic (US) examination with a 5.0-MHz and a 7.5-MHz probe. In 32 of 36 patients with malignant lymphoma (12 with Hodgkin disease, 24 with non-Hodgkin lymphoma) US showed a hypoechoic mass with a centrally located tubular structure. Pathologic examination showed that this structure correlated with small intact arterial vessels encased by confluent lymphomatous masses. This sonographic finding was not seen in patients with carcinomatous metastatic lesions to the lymph nodes (nine patients) or benign lymphadenitis (12 patients). The detection with US of small arteries within enlarged lymph nodes may indicate nodal infiltration by malignant lymphoma.

Small arteries in peripheral lymph nodes: a specific US sign of lymphomatous involvement.

Sonography of the pancreas was evaluated quantitatively in 94 normal subjects. The grey-scale values in the head and body of the pancreas were measured and compared with those of retroperitoneal fat. The echogenicity of the pancreas and the contrast between pancreas and fat were correlated with the age and weight of the subjects. Semi-quantitative studies revealed a positive correlation between echogenicity and age (r = 0.505); this can be confirmed to a high degree of statistical significance by quantitative analysis of pancreatic grey-scale values (r = 0.55 for the head and 0.71 for the body). Further improved correlation with age is obtained by computing the sonographic contrast between the pancreas and the retroperitoneal fat (r = 0.66 for the head and 0.77 for the body of the pancreas). It is concluded that determination of the grey-scale value can provide additional information particularly if one uses retroperitoneal fat as a reference tissue.

[The internal echo pattern of the normal pancreas. An assessment of the aging process and body weight dependence by sonographic gray-scale analysis].

The reproducibility of sonographic measurements was checked using 255 measurements on 57 intra-abdominal masses. It was shown that differences of measurements carried out independently by two observers increased in a linear manner with tumour diameter. Relative differences in measurement averaged 10%, but in 5% of cases they reached 30%. Somewhat better results were obtained with small tumours and for measurements lying strictly in the axis of the body. The significance of these findings in clinical practice, particularly for tumour follow-up, is discussed.

Majer Mc

Papers

Diagnosis of fistulae and sinus tracts in patients with Crohn disease: value of MR imaging

Small arteries in peripheral lymph nodes: a specific US sign of lymphomatous involvement.

[The internal echo pattern of the normal pancreas. An assessment of the aging process and body weight dependence by sonographic gray-scale analysis].

[Reproducibility of the sonographic determination of the size of intra-abdominal space-occupying lesions].