Department of Gastroenterology & Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
J Crohns Colitis. 2009 Dec;3(4):250-6. doi: 10.1016/j.crohns.2009.06.001. Epub 2009 Aug 22.
Many therapeutic decisions in the management of fistulizing and fibrostenotic Crohn's disease (CD) have to be taken without the benefit of strong scientific evidence. For this reason, explicit appropriateness criteria for CD fistula and stenosis treatment were developed by a multidisciplinary European expert panel in 2004 with the aim of making them easily available on the Internet and thus allowing individual case scenario evaluation; these criteria were updated in 2007.
Twelve international experts convened in Geneva, Switzerland in December 2007. Explicit clinical scenarios, corresponding to real daily practice, were rated on a 9-point scale based on evidence from the published literature and panelists' own expertise. Median ratings were stratified into three categories: appropriate (7-9), uncertain (4-6) and inappropriate (1-3).
Overall, panelists rated 60 indications pertaining to fistulas. Antibiotics, azathioprine/6-mercaptopurine and conservative surgery are the mainstay of therapy for simple and complex fistulas. In the event of previous failure of azathioprine/6-mercaptopurine therapy, methotrexate and infliximab were considered appropriate for complex fistulas. The panel also rated 72 indications related to the management of fibrostenotic CD. The experts considered balloon dilation, if the stricture was endoscopically accessible, stricturoplasty and bowel resection to be appropriate for small bowel fibrostenotic Crohn's disease, and balloon dilation and bowel resection appropriate for fibrostenotic colonic disease. In the presence of an ileocolonic or ileorectal anastomotic stricture of <7 cm, endoscopic balloon dilation, and bowel resection were considered appropriate.
Antibiotics, azathioprine/6-mercaptopurine, and conservative surgery are the mainstay of therapy for fistulizing Crohn's disease. Infliximab is a therapeutic option in patients without prior response to immunosuppressant therapy. In fibrostenotic Crohn's disease, endoscopic balloon dilation, if feasible, or surgical therapy should be considered. These expert recommendations are available online (www.epact.ch). Prospective evaluation is now needed to test the validity of these appropriateness criteria in clinical practice.
在管理瘘管性和纤维狭窄性克罗恩病（CD）时，许多治疗决策都需要在缺乏强有力的科学证据的情况下做出。出于这个原因，一个多学科的欧洲专家小组于 2004 年制定了明确的 CD 瘘管和狭窄治疗适宜性标准，目的是使这些标准能够在互联网上轻松获取，并允许对个别病例进行评估；这些标准在 2007 年进行了更新。
12 名国际专家于 2007 年 12 月在瑞士日内瓦开会。根据已发表的文献和小组成员的专业知识，对与真实日常实践相对应的明确临床情况进行了 9 分制评分。中位数评分分为三个类别：适宜（7-9）、不确定（4-6）和不适宜（1-3）。
总体而言，小组成员对 60 种瘘管相关的适应证进行了评分。抗生素、巯嘌呤/6-巯基嘌呤和保守手术是治疗单纯性和复杂性瘘管的主要方法。在巯嘌呤/6-巯基嘌呤治疗失败的情况下，甲氨蝶呤和英夫利昔单抗被认为是复杂性瘘管的适宜治疗方法。专家组还对 72 种与纤维狭窄性 CD 管理相关的适应证进行了评分。专家们认为，如果狭窄可通过内镜到达，则球囊扩张、狭窄成形术和肠切除术适用于小肠纤维狭窄性克罗恩病，而球囊扩张和肠切除术适用于纤维狭窄性结肠疾病。对于存在<7cm 的回肠结肠或回肠直肠吻合口狭窄，内镜球囊扩张和肠切除术被认为是合适的。
抗生素、巯嘌呤/6-巯基嘌呤和保守手术是治疗瘘管性克罗恩病的主要方法。对于没有免疫抑制剂治疗反应的患者，英夫利昔单抗是一种治疗选择。在纤维狭窄性克罗恩病中，如果可行，应考虑内镜球囊扩张或手术治疗。这些专家建议可在网上获得（www.epact.ch）。现在需要进行前瞻性评估，以检验这些适宜性标准在临床实践中的有效性。
