No abstract

Summary Background : Infliximab, a chimeric monoclonal antibody to tumour necrosis factor‐α, is a new potent therapy for active Crohn's disease, but induces short‐lived improvements. Aim : To evaluate the efficacy of thalidomide, a drug with anti‐tumour necrosis factor‐α activity, for the maintenance of infliximab‐induced response in refractory Crohn's disease. Methods : Fifteen patients with severe, refractory disease (10 females, five males; mean age, 40 years; eight with luminal disease, two with fistulizing disease and five with both luminal and fistulizing disease) were started on thalidomide (100 mg daily), 29 ± 10 days after they had responded to infliximab (5 mg/kg infusions). Results : The median follow‐up period was 238 days (range, 10–458 days) from the initiation of thalidomide and 265 days (range, 10–537 days) from the last infliximab infusion. The median Crohn's disease activity indices were 322 (range, 170–525), 119 (range, 24–503) and 35 (range, − 60–360) before infliximab, at the initiation of thalidomide and at the end of follow‐up, respectively. Remission rates on thalidomide were 92%, 83% and 83% at 3, 6 and 12 months, respectively, after the last infliximab infusion (Kaplan–Meier). Four patients (two in remission) stopped thalidomide for suspected adverse effects. Side‐effects (drowsiness, rash and peripheral neuropathy) were mild and mostly transient. Conclusions : Thalidomide appears to be an effective and relatively safe drug to maintain response to infliximab in chronically active and fistulizing refractory Crohn's disease.

Patients with CD exhibiting deep and extensive ulcerations at colonoscopy have a more aggressive clinical course with an increased rate of penetrating complications and surgery.

This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e9. Learning Objective-Upon completion of this activity, successful learners will be able to list risk factors for postoperative recurrence in Crohn's disease; list appropriate strategies to evaluate for early disease recurrence following surgery for Crohn's disease; and outline treatment options to reduce risk of postoperative recurrence in Crohn's disease, and strategies if early recurrence is identified. BACKGROUND AND AIMS: Different types of histologic lesions at the ileal margin, detected by histology, have been associated with increased rates of recurrence after ileocaecal surgery in patients with Crohn's disease (CD). We aimed to characterize histologic features of the ileal margin and to evaluate their association with disease recurrence. METHODS: We collected histologic data from 211 patients with ileal or ileocolonic CD who underwent ileocolonic resections at hospitals in France from September 2010 through December 2016. Ileal margins were analyzed. Early endoscopic recurrence was defined by a Rutgeerts score of i2 or more, 6 months after surgery. We also collected data from 10 adults with healthy ileum who underwent ileocecal resection for colonic tumors (controls). Clinical relapse was defined by CD-related symptoms confirmed by imaging, endoscopy, therapy intensification, CD-related complication, or subsequent surgery. RESULTS: Six months after surgery, 49% of patients had endoscopic recurrence; 5 years after surgery, 57% of patients had clinical relapse. Ileal margins were macroscopically affected in 20.9% of patients. CD transmural lesions at the margin (defined by mucosal ulceration or cryptitis, submucosal fibrosis and lymphoplasmacytic infiltrate of the subserosa) were observed in 13.6% of patients. Endoscopic recurrence was observed in 75% of patients with CD transmural lesions vs 46% of patients without (P [.005). In multivariate analysis, CD transmural lesions at the margin were independently associated with early endoscopic recurrence (OR, 3.83; 95% CI, 1.47-11.05; P [.008) and clinical recurrence (OR 2.04; 95% CI, 1.09-3.99; P [.026). CONCLUSION: In patients with CD, transmural lesions at the ileal margin were associated with an increased risk of post-operative recurrence. Histologic features of the ileal margin should be included in making decisions about post-operative therapy.

No abstract