Bardzo rzadkim powikłaniem pozajelitowym nieswoistych chorób zapalnych jelit jest pierwotne stwardniające zapalenie dróg żółciowych (PSC – primary sclerosing cholangitis), które częściej współwystępuje z wrzodziejącym zapaleniem jelita grubego. W chorobie Leśniowskiego-Crohna powikłanie to stwierdza się w 3% przypadków54. Objawy nie korelują ze stopniem zaostrzenia choroby jelit. Schorzenie w znacznym stopniu pogarsza rokowanie, zwiększa ryzyko raka dróg żółciowych i raka jelita grubego. Poza przeszczepieniem wątroby nieznane są inne metody skutecznego leczenia tego powikłania. Jedynym lekiem stosowanym w tym schorzeniu, który poprawia parametry laboratoryjne czynności wątroby, jest kwas ursodeoksycholowy podawany w dawce 15-20 mg/kg/24 h49,55.

Okulistyczne powikłania choroby Leśniowskiego-Crohna obejmują zapalenie nadtwardówki, twardówki i błony naczyniowej56.

Żylna choroba zakrzepowo-zatorowa stanowi zagrożenie życia u pacjentów z chorobą Leśniowskiego-Crohna. Ryzyko wystąpienia zakrzepicy żył głębokich i zatorowości płucnej jest mniej więcej dwukrotnie wyższe u tych pacjentów w porównaniu z populacją ogólną57. Czynnikami ryzyka są zaostrzenie choroby, hospitalizacja i niedawno przebyta hospitalizacja i/lub operacja. W tej grupie pacjentów jest wskazane stosowanie profilaktyki przeciwzakrzepowej49.

Podsumowanie

Choroba Leśniowskiego-Crohna jest nieuleczalną chorobą, powodującą znaczne pogorszenie jakości życia, a w skrajnych przypadkach może nawet doprowadzić do stanu jego zagrożenia. Znaczna część chorych w toku choroby wymaga przynajmniej jednej interwencji chirurgicznej. W ostatnich latach zwiększyły się możliwości diagnostyczne i terapeutyczne, szczególnie w zakresie leczenia biologicznego. Terapia pacjentów z chorobą Leśniowskiego-Crohna powinna być prowadzona w ośrodkach referencyjnych dysponujących odpowiednim zapleczem diagnostycznym i chirurgicznym.

Abstract

Crohn’s disease: diagnosis and therapeutic options

Crohn’s disease (CD) is an incurable condition that significantly reduces the quality of life and can be life-threatening in some cases. A significant number of patients require at least one surgical intervention during the course of the disease. The recent years have seen certain advancements in diagnostic and therapeutic methods, particularly in the area of biological treatment. It is reasonable to treat CD patients in specialized centers having appropriate diagnostic and surgical background.

Piśmiennictwo

1. Torres J, Mehandru S, Colombel JF, et al. Crohn’s disease. Lancet 2017;389:1741-55

2. Podolsky DK. Inflammatory bowel disease. N Engl J Med 2002;347:417-29

3. Day AS, Ledder O, Leach ST, et al. Crohn’s and colitis in children and adolescents. World J Gastroenterol 2012;18(41):5862-9

4. Cosnes J, Cattan S, Blain A, et al. Long-term evolution of disease behavior of Crohn’s disease. Inflamm Bowel Dis 2002;8:244-50

5. Kruis W, Katalinic A, Klugmann T, et al. Predictive factors for an uncomplicated long-term course of Crohn’s disease: a retrospective analysis. J Crohns Colitis 2013;7:e263-70

6. Danese S, Fiorino G, Peyrin-Biroulet L. Early intervention in Crohn’s disease: towards disease modification trials. Gut 2017;66:2179-87

7. Peyrin-Biroulet L, Loftus EV Jr, Colombel JF, et al. The natural history of adult Crohn’s disease in population-based cohorts. Am J Gastroenterol 2010;105:289-97

8. Maaser C, Sturm A, Vavricka SR, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. Journal of Crohn’s and Colitis 2019;2(13):144-164K

9. Masselli G, Casciani E, Polettini E, et al. Comparison of MR enteroclysis with MR enterography and conventional enteroclysis in patients with Crohn’s disease. Eur Radiol 2008;18(3):438-47

10. Zakeri N, Pollok RC. Diagnostic imaging and radiation exposure in inflammatory bowel disease. World J Gastroenterol 2016;22(7):2165-78

11. Dong J, Wang H, Zhao J, et al. Ultrasound as a diagnostic tool in detecting active Crohn’s disease: a meta-analysis of prospective studies. Eur Radiol 2014;24(1):26-33

12. Panés J, Bouzas R, Chaparro M, et al. Systematic review: the use of ultrasonography, computed tomography and magnetic resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn’s disease. Aliment Pharmacol Ther 2011;34(2):125-45

13. Greenup AJ, Bressler B, Rosenfeld G. Medical Imaging in Small Bowel Crohn’s Disease-Computer Tomography Enterography, Magnetic Resonance Enterography, and Ultrasound: “Which One Is the Best for What?”. Inflamm Bowel Dis 2016;22(5):1246-61

14. Taylor SA, Mallett S, Bhatnagar G, et al. Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohn’s disease (METRIC): a multicentre trial. Lancet Gastroenterol Hepatol 2018;3(8):548-58

15. Vermeire S, Van Assche G, Rutgeerts P. Laboratory markers in IBD: useful, magic, or unnecessary toys? Gut 2006;55:426-31

16. Bar-Gil Shitrit A, Koslowsky B, Livoversusky DM, et al. A prospective study of fecal calprotectin and lactoferrin as predictors of small bowel Crohn’s disease in patients undergoing capsule endoscopy. Scand J Gastroenterol 2017;52:328-33

17. Heida A, Park KT, van Rheenen PF. Clinical utility of fecal calprotectin monitoring in asymptomatic patients with inflammatory bowel disease: a systematic review and practical guide. Inflamm Bowel Dis 2017;23:894-902

18. Zubin G, Peter L. Predicting endoscopic Crohn’s disease activity before and after induction therapy in children: a comprehensive assessment of PCDAI, CRP, and fecal calprotectin. Inflamm Bowel Dis 2015;21:1386-91

19. Gisbert JP, Marín AC, Chaparro M. The risk of relapse after anti-TNF discontinuation in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol 2016;111:632-47

20. Lim WC, Wang Y, MacDonald JK, et al. Aminosalicylates for induction of remission or response in Crohn’s disease. Cochrane Database Syst Rev 2016;7:CD008870

21. Akobeng AK, Zhang D, Gordon M, et al. Oral 5-aminosalicylic acid for maintenance of medically-induced remission in Crohn’s disease. Cochrane Database Syst Rev 2016;9:CD003715

22. Rezaie A, Kuenzig ME, Benchimol EI, et al. Budesonide for induction of remission in Crohn’s disease. Cochrane Database Syst Rev 2015;6:CD000296

23. Benchimol EI, Seow CH, Steinhart AH, et al. Traditional corticosteroids for induction of remission in Crohn’s disease. Cochrane Database Syst Rev 2008;2:CD006792

24. Torres J, Bonovas S, Doherty G, et al. ECCO Guidelines on Therapeutics in Crohn’s Disease: Medical Treatment. Journal of Crohn’s and Colitis 2020;1(14):4-22

25. Summers RW, Switz DM, Sessions JTJr, et al. National cooperative Crohn’s disease study: results of drug treatment. Gastroenterology 1979;77:847-69

26. Candy S, Wright J, Gerber M, et al. A controlled double blind study of azathioprine in the management of Crohn’s disease. Gut 1995;37:674-8

27. Reinisch W, Panés J, Lémann M, et al. A multicenter, randomized, double-blind trial of everolimus versus azathioprine and placebo to maintain steroid-induced remission in patients with moderate-to-severe active Crohn’s disease. Am J Gastroenterol 2008;103:2284-92

28. Panés J, López-Sanromán A, Bermejo F, et al. Early azathioprine therapy is no more effective than placebo for newly diagnosed Crohn’s disease. Gastroenterology 2013;145:766-74.e1

29. Feagan BG, Rochon J, Fedorak RN, et al. Methotrexate for the treatment of Crohn’s disease. The North American Crohn’s Study Group Investigators. N Engl J Med 1995;332:292-7

30. Stidham RW, Lee TC, Higgins PD, et al. Systematic review with network meta-analysis: the efficacy of anti-TNF agents for the treatment of Crohn’s disease. Aliment Pharmacol Ther 2014;39:1349-62

31. Cholapranee A, Hazlewood GS, Kaplan GG, et al. Systematic review with meta-analysis: comparative efficacy of biologics for induction and maintenance of mucosal healing in Crohn’s disease and ulcerative colitis controlled trials. Aliment Pharmacol Ther 2017;45:1291-302

32. Ford AC, Sandborn WJ, Khan KJ, et al. Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol 2011;106:644-59

33. Sandborn WJ, Feagan BG, Rutgeerts P, et al.; GEMINI 2 Study Group. Vedolizumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 2013;369:711-21

34. MacDonald JK, Nguyen TM, Khanna R, et al. Anti-IL-12/23p40 antibodies for induction of remission in Crohn’s disease. Cochrane Database Syst Rev 2016;11:CD007572

35. Colombel JF, Sandborn WJ, Reinisch W, et al.; SONIC Study Group. Infliximab, azathioprine, or combination therapy for Crohn’s disease. N Engl J Med 2010;362:1383-95

36. Matsumoto T, Motoya S, Watanabe K, et al.; DIAMOND study group. Adalimumab monotherapy and a combination with azathioprine for Crohn’s disease: a prospective, randomized trial. J Crohns Colitis 2016;10:1259-66

37. Kawalec P, Moćko P. An indirect comparison of ustekinumab and vedolizumab in the therapy of TNF-failure Crohn’s disease patients. J Comp Eff Res 2018;7:101-11

38. de Groof EJ, Carbonnel F, Buskens CJ, et al. Abdominal abscess in Crohn’s disease: multidisciplinary management. Dig Dis 2014;32(Suppl 1):103-9

39. Bartnik W, Wejman J. Atlas kliniczno-patologiczny nieswoistych chorób zapalnych jelit. Poznań: Wydawnictwa Medyczne „Termedia”, 2017:113-27

40. Grimaud JC, Munoz-Bongrand N, Siproudhis L, et al.; Groupe d’Etude Thérapeutique des Affections Inflammatoires du Tube Digestif. Fibrin glue is effective healing perianal fistulas in patients with Crohn’s disease. Gastroenterology 2010;138:2275-81

41. Lee WY, Park KJ, Cho YB, et al. Autologous adipose tissue-derived stem cells treatment demonstrated favorable and sustainable therapeutic effect for Crohn’s fistula. Stem Cells 2013;31:2575-81

42. Sirany AM, Nygaard RM, Morken JJ. The ligation of the intersphincteric fistula tract procedure for anal fistula: a mixed bag of results. Dis Colon Rectum 2015;58:604-12

43. Brennan GT, Ha I, Hogan C, et al. Does preoperative enteral or parenteral nutrition reduce postoperative complications in Crohn’s disease patients: a meta-analysis. Eur J Gastroenterol Hepatol 2018;30:997-1002

44. Huang W, Tang Y, Nong L, et al. Risk factors for postoperative intra-abdominal septic complications after surgery in Crohn’s disease: a meta-analysis of observational studies. J Crohns Colitis 2015;9:293-301

45. Xu Y, Yang L, An P, et al. Meta-analysis: the influence of preoperative infliximab use on postoperative complications of Crohn’s disease. Inflamm Bowel Dis 2019;25:261-9

46. Requena L, Sanchez Yus E. Erythema nodosum. Semin Cutan Med Surg 2007;26:114-25

47. Trost LB, McDonnell JK. Important cutaneous manifestations of inflammatory bowel disease. Postgrad Med J 2005;81:580-5

48. Vavricka SR, Schoepfer A, Scharl M, et al. Extraintestinal Manifestations of Inflammatory Bowel Disease. Inflamm Bowel Dis 2015;21(8):1982-92

49. Harbord M, Annese V, Vavricka SR, et al. The First European Evidence-based Consensus on Extra-intestinal Manifestations in Inflammatory Bowel Disease. Journal of Crohn’s and Colitis 2016;3(10):239-54

50. Rodríguez-Reyna TS, Martínez-Reyes C, Yamamoto-Furusho JK. Rheumatic manifestations of inflammatory bowel disease. World J Gastroenterol 2009;15:5517-24

51. Rudwaleit M, van der Heijde D, Landewé R, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Annals of the Rheumatic Diseases 2009;68:777-83

52. Bourikas LA, Papadakis KA. Musculoskeletal manifestations of inflammatory bowel disease. Inflammatory Bowel Diseases 2009;15:1915-24

53. Bourikas LA, Papadakis KA. Musculoskeletal Manifestations of Inflammatory Bowel Disease. Inflammatory Bowel Diseases 2009;12(15):1915-24

54. Tsaitas C, Semertzidou A, Sinakos E. Update on inflammatory bowel disease in patients with primary sclerosing cholangitis. World J Hepatol 2014;6(4):178-87

55. Trauner M, Halilbasic E, Baghdasaryan A, et al. Primary sclerosing cholangitis: new approaches to diagnosis, surveillance and treatment. Dig Dis 2012;30(Suppl 1):39-47

56. Mintz R, Feller ER, Bahr RL, et al. Ocular manifestations of inflammatory bowel disease. Inflamm Bowel Dis 2004;10:135-9

57. Yuhara H, Steinmaus C, Corley D, et al. Meta-analysis: the risk of venous thromboembolism in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2013;37:953-62

Do góry