Journal of Crohn's and Colitis (2010) 4,63–101 available at www.sciencedirect.com SPECIAL ARTICLE The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations Gert Van Assche ⁎,1, Axel Dignass ⁎,1, Walter Reinisch, C. Janneke van der Woude, Andreas Sturm, Martine De Vos, Mario Guslandi, Bas Oldenburg, Iris Dotan, Philippe Marteau, Alessandro Ardizzone, Daniel C. Baumgart, Geert D'Haens, Paolo Gionchetti, Francisco Portela, Boris Vucelic, Johan Söderholm, Johanna Escher, Sibylle Koletzko, Kaija-Leena Kolho, Milan Lukas, Christian Mottet, Herbert Tilg, Séverine Vermeire, Frank Carbonnel, Andrew Cole, Gottfried Novacek, Max Reinshagen, Epameinondas Tsianos, Klaus Herrlinger, Bas Oldenburg, Yoram Bouhnik, Ralf Kiesslich, Eduard Stange, Simon Travis, James Lindsay for the European Crohn's and Colitis Organisation (ECCO) Received 19 August 2009; received in revised form 28 September 2009; accepted 28 September 2009 KEYWORDS Crohn's disease: post-operative recurrence; Fistula; Paediatric; Pregnancy; Psychosomatic; Extraintestinal manifestation ⁎ Corresponding authors. Van Assche is to be contacted at Division of Gastroenterology, Leuven University Hospitals, 49 Herestraat, BE 3000, Leuven, Belgium. Tel.: +32 16 34 42 25; fax: +32 16 34 44 19. Dignass, Department of Medecine I, Markus-Krankenhaus, Wilhelm-Epstein-Strasse 4, DE-60431 Frankurt/Main, Germany. Tel.: +49 69 9533 2201; fax: +49 69 9533 2291. E-mail addresses: [email protected] (G. Van Assche), [email protected] (A. Dignass). 1 These authors acted as convenors of the Consensus and contributed equally to the work. 1873-9946/$ - see front matter © 2009 Published by Elsevier B.V. on behalf of European Crohn's and Colitis Organisation. doi:10.1016/j.crohns.2009.09.009 64 G. Van Assche et al. Contents 8. Risk factors, prophylaxis, diagnosis and management of post-operative recurrence of Crohn's disease ......... 65 8.1. Epidemiology of post-operative Crohn's disease ................................... 65 8.2. Predicting post-operative recurrence......................................... 66 8.3. Diagnosis of post-operative recurrence........................................ 66 8.4. Medical prophylaxis................................................... 66 8.4.1. Mesalazine ................................................... 67 8.4.2. Antibiotics ................................................... 67 8.4.3. Thiopurines................................................... 67 8.4.4. Anti-TNF agents ................................................ 68 8.4.5. Other therapies ................................................ 68 9. Diagnosis and management of fistulating Crohn's disease ................................... 68 9.1. Introduction ....................................................... 68 9.2. Perianal fistulae .................................................... 68 9.3. Non-perianal fistulae .................................................. 69 9.4. Diagnosis of perianal fistulae ............................................. 69 9.4.1. Initial diagnostic approach .......................................... 69 9.4.2. Classification of perianal fistulae ...................................... 69 9.5. Treatment of fistulating disease ........................................... 69 9.5.1. Simple perianal fistulae............................................ 69 9.5.2. Complex perianal disease........................................... 70 9.5.3. Medical therapy ................................................ 70 9.5.4. Surgical procedures for perianal Crohn's disease . ........................... 71 9.5.5. Monitoring the therapeutic response .................................... 71 9.6. Continuing therapy for perianal Crohn's disease................................... 71 9.6.1. Consensus views ................................................ 72 9.6.2. Therapeutic approach in the event of infliximab failure ......................... 72 9.6.3. Surgical intervention in conjunction with infliximab treatment ...................... 72 9.7. Management of non-perianal fistulating Crohn's disease . ........................... 72 9.7.1. Enterocutaneous fistulae ........................................... 72 9.7.2. Enterogynaecological fistulae ........................................ 72 10. Crohn's disease in children and adolescents: diagnosis and treatment ........................... 72 10.1. Introduction ....................................................... 72 10.2. Diagnosis......................................................... 73 10.3. Treatment ........................................................ 74 10.3.1. General ..................................................... 74 10.3.2. Induction therapy ............................................... 74 10.3.3. Maintenance therapy ............................................. 74 10.3.4. Refractory disease............................................... 75 10.4. Supportive management ................................................ 76 10.5. Conclusions ....................................................... 76 11. The management of pregnancy in Crohn's disease ....................................... 76 11.1. Fertility in Crohn's disease............................................... 76 11.2. Influence of disease activity on the course and outcome of pregnancy...................... 77 11.3. The influence of pregnancy on the course of CD ................................... 77 11.4. Mode of delivery .................................................... 77 11.5. Surgery during pregnancy ............................................... 78 11.6. Medical treatment during pregnancy ......................................... 78 11.6.1. Aminosalicylates in pregnancy ........................................ 78 11.6.2. Antibiotics in pregnancy ........................................... 78 11.6.3. Corticosteroids in pregnancy ......................................... 78 11.6.4. Budesonide in pregnancy ........................................... 78 11.6.5. Thiopurines in pregnancy ........................................... 79 11.6.6. Ciclosporin in pregnancy ........................................... 79 11.6.7. Tacrolimus in pregnancy ........................................... 79 11.6.8. Methotrexate in pregnancy .......................................... 79 11.6.9. Anti-TNF therapy in pregnancy........................................ 79 11.6.10.Thalidomideinpregnancy........................................... 79 11.6.11.AgentsforsymptomaticreliefofCrohn'sdiseaseinpregnancy....................... 80 11.7. Medical treatment when breast feeding ....................................... 80 ECCO Consensus on CD: Special situations 65 12. Crohn's disease and psychosomatics .............................................. 80 12.1. Introduction ....................................................... 80 12.2. Psychosocial factors................................................... 80 12.3. Psychological factors influencing the course of Crohn's disease .......................... 80 12.4. Doctor–patient relationship, information and clinical care. .......................... 81 12.5. Assessment of health related quality of life, psychological distress and provision of integrated psychological support .......................................................... 81 12.6. Psychotherapeutic interventions. ........................................... 81 12.6.1. Psychotherapy ................................................. 81 12.6.2. Choice of psychotherapeutic methods and psycho-pharmaceuticals ................... 82 13. Extraintestinal manifestations of Crohn's disease ....................................... 82 13.1. Introduction ....................................................... 82 13.2. Arthropathy ....................................................... 82 13.2.1. Peripheral arthropathy ............................................ 82 13.2.2. Axial arthropathy ............................................... 82 13.2.3. Treatment of arthropathy related to Crohn's disease. .......................... 83 13.3. Metabolic bone disease................................................. 83 13.4. Cutaneous manifestations ............................................... 84 13.4.1. Erythema nodosum (EN)............................................ 84 13.4.2. Pyoderma gangrenosum (PG) ......................................... 84 13.4.3. Sweet's syndrome ............................................... 84 13.5. Ocular manifestations ................................................. 85 13.6. Hepatobiliary disease .................................................. 85 13.7. Venous thromboembolism ............................................... 86 13.8. Cardiopulmonary disease ................................................ 86 14. Alternative therapies for CD................................................... 86 14.1. Introduction ...................................................... 86 14.2. Confounding factors. .................................................. 87 14.3. Definitions ........................................................ 87 14.4. Use and prevalence of CAM .............................................. 87 14.5. Choice and evidence .................................................. 87 14.6. Conclusions ....................................................... 88 Contributors .............................................................. 88 Acknowledgements .........................................................