Second Korean Guidelines for the Management of Crohn's Disease

Jae Jun Park; Suk-Kyun Yang; Byong Duk Ye; Jong Wook Kim; Dong Il Park; Hyuk Yoon; Jong Pil Im; Kang Moon Lee; Heeyoung Lee

doi:10.4166/kjg.2017.69.1.29

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Park, Yang, Ye, Kim, Park, Yoon, Im, Lee, Lee, and IBD Study Group of the Korean Association for the Study of the Intestinal Diseases: Second Korean Guidelines for the Management of Crohn's Disease

Review Article

Korean J Gastroenterol 2017;69(1):29-54.

Published online: 4 October 2017

DOI: https://doi.org/10.4166/kjg.2017.69.1.29

Second Korean Guidelines for the Management of Crohn's Disease

Jae Jun Park¹, Suk-Kyun Yang², Byong Duk Ye², Jong Wook Kim³, Dong Il Park⁴, Hyuk Yoon⁵, Jong Pil Im⁶, Kang Moon Lee⁷, Heeyoung Lee⁹; IBD Study Group of the Korean Association for the Study of the Intestinal Diseases

¹Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea

²Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea

³Department of Internal Medicine, Inje University College of Medicine Ilsan Paik Hospital, Goyang, Korea

⁴Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea

⁵Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

⁶Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea

⁷Department of Internal Medicine, The Catholic University of Korea College of Medicine, Suwon, Korea

⁸Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea

⁹Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea

Correspondence to: Suk-Kyun Yang, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3901, Fax: +82-2-476-0824, E-mail: sky@amc.seoul.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Crohn's disease (CD) is a chronic, progressive, and disabling inflammatory bowel disease (IBD) with an uncertain etiopathogenesis. CD can involve any site of the gastrointestinal tract from the mouth to the anus, and is associated with serious complications, such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower compared with those in Western countries, but they have been rapidly increasing during the recent decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies have been applied for the treatment of this disease. Concerning CD management, there have been substantial discrepancies among clinicians according to their personal experience and preference. To suggest recommendable approaches to the diverse problems of CD and to minimize the variations in treatment among physicians, guidelines for the management of CD were first published in 2012 by the IBD Study Group of the Korean Association for the Study of the Intestinal Diseases. These are the revised guidelines based on updated evidence, accumulated since 2012. These guidelines were developed by using mainly adaptation methods, and encompass induction and maintenance treatment of CD, treatment based on disease location, treatment of CD complications, including stricture and fistula, surgical treatment, and prevention of post-operative recurrence. These are the second Korean guidelines for the management of CD and will be continuously revised as new evidence is collected.

Keywords: Crohn's disease, Treatment, Guidelines

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Table 1.

Eight Guidelines Selected with AGREE II Instrument^6–13

No.	Title	Country/ Language	Journal	Year	Volume/Page
1	The London Position Statement of the World Congress of Gastroenterology on Biological Therapy for IBD With the European Crohn's and Colitis Organization: When to Start, When to Stop, Which Drug to Choose, and How to Predict Response?	UK/English	Am J Gastroenterol	2011	106:199–212
2	The Italian Society of Gastroenterology (SIGE) and the Italian Group for the study of Inflammatory Bowel Disease (IG-IBD) Clinical Practice Guidelines: The use of tumor necrosis factor-alpha antagonist therapy in Inflammatory Bowel Disease	Italy/English	Dig Liver Dis	2011	43: 1–20
3	Guidelines for the management of inflammatory bowel disease in adults (British Society of Gastroenterology)	UK/English	Gut	2012	60:571–607
4	Crohn's Disease: Management in Adults, Children and Young People^*	UK/English	NA	2012	NA: 1–398
5	American Gastroenterological Association Institute Guideline on the Use of Thiopurines, Methotrexate, and Anti– TNF-α Biologic Drugs for the Induction and Maintenance of Remission in Inflammatory Crohn's Disease	USA/English	Gastroenterology	2013	145:1459–1463
6	Evidence-based clinical practice guidelines for Crohn's disease, integrated with formal consensus of experts in Japan	Japan/English	J Gastroenterol	2013	48:31–72
7	A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease	Netherlands/English	Gut	2014	63:1381–1392
8	The Asia Pacific Consensus Statements on Crohn's Disease Part 2: Management1 (Asia Pacific Association of Gastroenterology [APAGE] Working Group on Inflammatory Bowel Disease.)	Australia/English	J Gastroenterol Hepatol	2016	31:56–68

AGREE, appraisal of guidelines research and evaluation; NA, not applicable.

^* Guideline is freely available on the web (https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0068978/).

Table 2.

Definitions or Implications of the Levels of Evidence and Recommendations^14–17

Level	Definitions/implications
Quality of evidence
High	We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate	We are moderately confident about the effect estimate: The true effect is most likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low	Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low	We have very little confidence in the effect estimate: The true effect is most likely to be substantially different from the estimate of the effect.
Classification of recommendations
Strong	Most patients should receive the recommended course of action.
Weak	Clinicians should recognize that different choices would be appropriate for different patients and that they must help patients to arrive at a management decision consistent with his or her values and preferences.

Table 3.

Crohn's Disease Activity Index

No	Items	Description		Multiplier
1	Number of liquid or very soft stools	Sum of 7 days.		×2
2	Abdominal pain	Sum of 7 days.	0 = none, 1 = mild, 2 = moderate, 3 = severe	×5
3	General well-being	Sum of 7 days.	0 = generally well, 1 = slightly under par, 2 = poor, 3 = very poor, 4 = terrible	×7
4	Number of 6 listed categories patient now has	Number of six listed categories	1) Arthritis/arthralgia	×20
			2) Iritis/uveitis
			3) Erythema nodosum/pyoderma gangrenosum/aphthous stomatitis
			4) Anal fissure, fistula, or abscess
			5) Other fistula
			6) Fever > 37.8°C (100°F) during the past week
5	Antidiarrheal drug use	Use in the previous 7 days	0 = no, 1 = yes	×30
6	Abdominal mass		0 = none, 2 = questionable, 5 = definite	×10
7	Hematocrit	Expected-observed	Males: [47-hematocrit]	×6
		Hematocrit	Females: [42-hematocrit]
8	Body weight	Percent below standard weight (normogram)		×1

Table 4.

Harvey-Bradshaw Simple Index

Variable	Description	Scoring
1	General well-being	(0=very well, 1=slightly below par, 2=poor, 3=very poor, 4=terrible)
2	Abdominal pain	(0=none, 1=mild, 2=moderate, 3=severe)
3	Number of liquid stools daily	1 per occurrence
4	Abdominal mass	(0=none, 1=dubious, 2=definite, 3=definite and tender)
5	Complications	1 per item:
		• Arthralgia • Uveitis • Erythema nodosum • Aphthous ulcer • Pyoderma gangrenosum
		• Anal fissure • New fistula • Abscess
Total score		Sum of variable scores

Table 5.

Montreal Classification for Crohn's Disease

Age at diagnosis	A1 below 16 year
	A3 above 40 year A2 between 17 and 40 year
Location	L1 ileal
	L2 colonic
	L3 ileocolonic
	L4 isolated upper disease*
Behavior	B1 non‐ stricturing, non‐ penetrating
	B2 stricturing
	B3 penetrating
	p perianal disease modifier^†

^* L4 is a modifier that can be added to L1– L3 when concomitant upper gastrointestinal disease is present.

^† “p” is added to B1– B3 when concomitant perianal disease is present.

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