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Crohn’s Disease Flare Pathway

Flare pathway for adults with known Crohn’s Disease without a stoma or an individual care plan. Exclusions : age under 16 , have a stoma or fistula , have had surgery or are on immunomodulators – azathioprine , mercaptopurine , methotrexate or a biological therapy ( e.g. Humira )

Exclude intercurrent gastrointestinal infection . Ask about triggers . Check adherence to medication. Stop NSAIDS. Consider self-care for mild symptoms including dietary advice and reducing stress. See rcgp.org.uk/ibd and signpost to crohnsandcolitis.org.uk. Check inflammatory blood markers and faecal calprotectin , but initiate treatment before results are available if clinical suspicion is high.

Where is the main site of onset Perinal – is there a hot fluctuant swelling or is the patient vomiting ? Phone on-call surgical SpR No – Metronidazole or ciprofloxacin ( unlicenced indications ) alone or in combination , can improve symptoms of fistulating Crohn’s but complete healing occurs rarely. Metronidazole is usually given for 1 month , but no longer than 3 months because of peripheral neuropathy concerns. Discuss all cases of perianal Crohn’s with the IBD team.

Ileal or ileo-colonic – are there obvious signs of obstruction ( vomiting , post-prandial pain and weight loss ) or fevers or a palpable mass ?  No In any flare arrange bloods and stool cultures. Patients with Crohns are at increased risk of abscess formation . If there are any concerns arrange USS. No evidence of penetration Budesonide ( Budenofalk or Enterocort ) 9 mg/ day for 8 weeks , consider tapering off for 2-4 weeks after. Inform the IBD team , when oral steroids are given. Patients should not have more than 1 course of steroids in a year without considering escalating steroids sparing agents.

are there obvious signs of obstruction ( vomiting , post-prandial pain and weight loss ) or fevers or a palpable mass ?- yes may need admission discuss with on-call gastro-team

Colonic – are there obvious signs of obstruction ( vomiting , post-prandial pain and weight loss ) or fevers or a palpable mass ? No Patients with Crohns are at increased risk of abscess formation ideally arrange US bloods and stool culture
No evidence of penetration

Oral prednisolone 40 mg / day for 7 days then reducing by 5 mg/ week over 8 weeks = 252 x 5 mg prednisolone tablets in total. Remember GI and bone protection. Counsel re : side effects.

Inform the IBD team , when oral steroids are given. Patients should not have more than 1 course of steroids in a year without considering escalating steroids sparing agents.

LINKS AND RESOURCES

 

RCGP IBD Toolkit produced in partnership with Crohns & Colitis UK https://www.rcgp.org.uk/ibd

Crohns and Colitis UK patient information resource on Crohns disease https://www.crohnsandcolitis.org.uk/about-crohns-and-colitis/publications/crohns-disease

European Crohns and Colitis Organisation physician resource – a huge collection on IBD http://www.e-guide.ecco-ibd.eu/resources

American College of Gastroenterology information for patients https://gi.org/topics/inflammatory-bowel-disease/#tabs2

Crohns Colitis Foundation -A large NY based charity working in association with American College of Gastroenterology https://www.crohnscolitisfoundation.org/

Biologics for Crohns disease – from Crohns and Colitis Foundation https://www.crohnscolitisfoundation.org/sites/default/files/legacy/assets/pdfs/biologic-therapy.pdf

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