Appropriate therapy for fistulizing and fibrostenotic Crohn's disease: results of a multidisciplinary expert panel - EPACT II

Details

Serval ID
serval:BIB_4A94FD300101
Type
Article: article from journal or magazin.
Collection
Publications
Institution
Title
Appropriate therapy for fistulizing and fibrostenotic Crohn's disease: results of a multidisciplinary expert panel - EPACT II
Journal
Journal of Crohns and Colitis
Author(s)
Felley Christian, Vader John-Paul, Juillerat Pascal, Pittet Valérie, O'Morain Colm, Panis Yves, Vucelic Boris, Gonvers Jean-Jacques, Mottet Christian, Froehlich Florian, Michetti Pierre
ISSN
1873-9946
Publication state
Published
Issued date
2009
Peer-reviewed
Oui
Volume
3
Number
4
Pages
250-256
Language
english
Abstract
Introduction: Many therapeutic decisions in the management of fistulizing and fibrostenotic Crohn's disease (CD) have to be taken without the benefit of strong scientific evidence. For this reason, explicit appropriateness criteria for CD fistula and stenosis treatment were developed by a multidisciplinary European expert panel in 2004 with the aim of making them easily available on the Internet and thus allowing individual case scenario evaluation; these criteria were updated in 2007. Methods: Twelve international experts convened in Geneva, Switzerland in December 2007. Explicit clinical scenarios, corresponding to real daily practice, were rated on a 9-point scale based on evidence from the published literature and panelists' own expertise. Median ratings were stratified into three categories: appropriate (7-9), uncertain (4-6) and inappropriate (1-3). Results: Overall, panelists rated 60 indications pertaining to fistulas. Antibiotics, azathioprine/6-mercaptopurine and conservative surgery are the mainstay of therapy for simple and complex fistulas. In the event of previous failure of azathioprine/6-mercaptopurine therapy, methotrexate and infliximab were considered appropriate for complex fistulas. The panel also rated 72 indications related to the management of fibrostenotic CD. The experts considered balloon dilation, if the stricture was endoscopically accessible, stricturoplasty and bowel resection to be appropriate for small bowel fibrostenotic Crohn's disease, and balloon dilation and bowel resection appropriate for fibrostenotic colonic disease. In the presence of an ileocolonic or ileorectal anastomotic stricture of <7 cm, endoscopic balloon dilation, and bowel resection were considered appropriate. Conclusion: Antibiotics, azathioprine/6-mercaptopurine, and conservative surgery are the mainstay of therapy for fistulizing Crohn's disease. Infliximab is a therapeutic option in patients without prior response to immunosuppressant therapy. In fibrostenotic Crohn's disease, endoscopic balloon dilation, if feasible, or surgical therapy should be considered. These expert recommendations are available online (www.epact.ch). Prospective evaluation is now needed to test the validity of these appropriateness criteria in clinical practice. (C) 2009 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.
Keywords
Crohn's disease, Fistulas, Stenosis, Appropriateness, RAND Appropriateness Method, Metronidazole
Web of science
Open Access
Yes
Create date
06/01/2010 10:43
Last modification date
20/08/2019 13:58
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