Given the complexity and heterogeneity of the disease and the different options for combining therapy, it is unlikely that sufficient controlled trials will ever be conducted to provide evidence for the best treatment for every clinical scenario. In many patients, several therapeutic options may represent valid alternatives. In this field, as in many others, patient preference should be an important factor in determining the choice of therapy. All physicians need to be aware that smoking is the most important risk factor statistically associated with Crohn's disease, with higher relapse rates following surgical resections and a greater risk of perforating disease [5, 6]. In a patient with a classical clinical ileal/colonic manifestation, there are many valid options including antibiotics, steroids, immunosuppressives, enteral nutrition and surgery.
A typical ileitis with poor response to medical therapy, and consequently poor quality of life for the patient, is a clear and unquestionable indication for surgery. On the other hand, a patient with multiple ileal localisations of the disease has to be conservatively managed for as long as possible.
In any severe situation, we should consider the great impact of the quality of nutrition on the state of the intestinal wall. Enteral nutrition employed as the only source of feeding is an effective therapy for Crohn's disease and its mechanism of action, although poorly understood, consists of an immunomodulatory procedure on the bowel mucosa, which consequently effects the bacterial flora. An elemental or polymeric diet is equally effective [7, 8].
Perineal disease occurs in up to one third of patients with Crohn's disease, impacting differently according to the different clinical phenotypes: ileal CD 12%, ileo-cecal CD 15%, colonic CD 41%, colorectal CD 92% . The medical management of per-ineal disease has been absolutely unsatisfactory with poor results in the short as well as in the long term. The availability of infliximab made it possible to greatly improve our results, which were even better when infliximab was associated with local non-invasive surgery such as drainage of fluid collection, fis-tulotomy or application of setons .
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