A global consensus on the definitions, diagnosis and management of fibrostenosing small bowel Crohn's disease in clinical practice

Abstract

Fibrostenosis of the small bowel is common in patients with Crohn's disease. No consensus recommendations on definition, diagnosis and management in clinical practice are currently available. In this Consensus Statement, we present a clinical practice RAND/UCLA appropriateness study on the definition, diagnosis and clinical management of fibrostenosing Crohn's disease. It was conducted by a panel of 28 global experts and one patient representative. Following a systematic literature review, 526 candidate items grouped into 136 questions were generated and subsequently evaluated for appropriateness. Strictures are best defined as wall thickening, luminal narrowing and prestenotic dilation. Cross-sectional imaging is required for accurate diagnosis of fibrostenosing Crohn's disease, and it is recommended before making treatment decisions. It should also assess the degree of inflammation in the bowel wall. Multiple options for medical anti-inflammatory, endoscopic and surgical therapies were suggested, including follow-up strategies following therapy. This Consensus Statement supports clinical practice through providing guidance on definitions, diagnosis and therapeutic management of patients with fibrostenosing small bowel Crohn's disease.

Fig. 1 |. Diagnosis, definitions and differentiation of fibrostenosing Crohn’s disease in clinical practice.

a, Modalities that were considered appropriate (blue) or inappropriate (red) by the panel to diagnose fibrostenosis. b, Best features to define fibrostenosing Crohn’s disease (CD) on cross-sectional imaging. Each survey item was classified as inappropriate (red), uncertain (yellow) or appropriate (blue) based on the median panel rating and degree of panel disagreement (median 1 to 3 without disagreement considered inappropriate; median 4 to 6 or any median with disagreement considered uncertain; median 7 to 9 without considered disagreement appropriate; the results of the individual appropriateness voting on the best features and their combinations for naive and anastomotic fibrostenosing CD are provided in Supplementary Table 1). c, Modalities to differentiate inflammation from fibrosis in fibrostenosing CD. While several diagnostic modalities were considered appropriate (blue) for identifying active inflammation, no cross-sectional imaging modality is currently available to accurately determine the degree of fibrosis (red) in fibrostenosing CD (results of the individual appropriateness voting on modalities to differentiate inflammation from fibrosis in fibrostenosing CD are provided in Supplementary Table 1). IUS, intestinal ultrasonography; MR, magnetic resonance; OP, operative. *Any of these required for diagnosis of fibrostenosing CD.

Fig. 2 |. Rating of appropriateness of medical treatment options for fibrostenosing Crohn’s disease.

Patients with naive (part a) and anastomotic (part b) fibrostenosing Crohn’s disease (CD). The level of appropriateness is reflected by the medians (30%, 70%) of the ratings. Each survey item was classified as inappropriate (red), uncertain (yellow) or appropriate (blue) based on the median panel rating and degree of panel disagreement (median 1 to 3 without disagreement considered inappropriate; median 4 to 6 or any median with disagreement considered uncertain; median 7 to 9 without disagreement considered appropriate; the results of the individual appropriateness voting on medical treatment options for fibrostenosing CD are provided in Supplementary Table 1). 5-ASA, 5-aminosalicylic acid. Adapted with permission from ref. , ECCO.