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Crohn's Disease Surgical Planning Algorithm (ASCRS)

Crohn's Disease Surgical Planning Algorithm (ASCRS): Adult Crohn's disease: planning surgery → Emergency: perforation, uncontrolled bleeding or failing ...

Pathway Overview

17 steps

Algorithm Steps

17 total

  1. 01Start

    Adult Crohn's disease: planning surgery

    Adults (18 years and over). Plan with a gastroenterologist and a colorectal surgeon. Children: paediatric IBD team.

  2. 02Decision

    Emergency: perforation, uncontrolled bleeding or failing severe colitis?

    Free perforation or peritonitis, bleeding despite resuscitation, toxic megacolon, or severe colitis not responding to medical therapy.

  3. If Yes
    1. 03Outcome

      Emergency: urgent colorectal surgical review and surgery

      Free perforation: resect the perforated segment. Bleeding: endoscopy or angiography if stable; operate if unstable despite resuscitation. Severe Crohn's colitis: total abdominal colectomy with end ileostomy. Current or recent steroids: give IV steroid cover. VTE prophylaxis from admission unless actively bleeding. Pregnant: operate if indicated at any gestation, with obstetric input.

    If No
    1. 04Warning

      No emergency: control sepsis before elective surgery or biologic therapy

      • Abdominal abscess: IV antibiotics. Add percutaneous drainage if 3 cm or larger. Then interval resection or medical therapy.
      • Perianal abscess: examination under anaesthesia (EUA), drainage and a loose draining seton.
      • Do not start anti-TNF or other biologic therapy until the abscess is drained or has resolved on antibiotics.
    2. 05Warning

      Before elective surgery: steroid cover and pregnancy

      • Current or recent steroids: give IV steroid cover for surgery. Do not stop steroids abruptly.
      • Pregnancy: same indications for surgery. Plan with obstetrics and the IBD team. Do not delay urgent surgery.
    3. 06Action

      Elective surgery: optimise the patient first

      • Wean corticosteroids if possible. Infection risk rises above prednisolone 20 mg/day (or equivalent).
      • Malnutrition: give nutritional support before surgery.
      • Stop smoking.
      • Correct anaemia.
      • Immunomodulators can continue. Do not delay surgery only because of biologic therapy.
    4. 07Decision

      Which site needs surgery?

      More than one site: follow each branch that applies.

    5. Ileocolic
    6. 08Action

      Ileocolic disease (terminal ileum and caecum)

      • Surgery if medical therapy fails, is not tolerated or is not taken, or if steroid dependent.
      • Short (under 40 cm), inflammatory, non-stricturing disease: laparoscopic resection is a reasonable option instead of starting a biologic.
      • Stricture, fistula or abscess not controlled by medical therapy: resection.
    7. 09End

      Ileocolic: laparoscopic ileocolic resection

      Resect only about 2 cm of normal bowel each side. Anastomosis type by surgeon preference. Temporary ileostomy if several risk factors (high-dose steroids, malnutrition, anaemia, smoking, abscess). After surgery: medical therapy to prevent recurrence; ileocolonoscopy at 6 months.

    8. Small bowel
    9. 10Action

      Small bowel or gastroduodenal disease (stricture or fistula)

      • Inflammatory stricture: medical therapy first.
      • Short (under 5 cm), non-inflammatory stricture with no abscess or fistula: consider endoscopic balloon dilation.
      • Multiple strictures, prior resection or short bowel risk: preserve bowel length.
      • Biopsy any suspicious lesion before stricturoplasty.
      • Stomach or duodenum: endoscopic dilation, bypass or stricturoplasty.
      • Enteric fistula that persists despite medical therapy: resect the diseased segment.
    10. 11End

      Small bowel: stricturoplasty or limited resection

      Stricturoplasty by length: Heineke-Mikulicz under 10 cm; Finney 10 to 25 cm; side-to-side isoperistaltic over 25 cm. Resect instead if perforation, abscess or inflammatory mass (phlegmon), dysplasia or cancer, or severe malnutrition.

    11. Colon
    12. 12Action

      Colonic Crohn's disease

      • Colonic stricture: colonoscopy with multiple biopsies. 2 to 6% contain dysplasia or cancer.
      • Stricture that cannot be fully examined: resect on oncological principles.
      • Do not do colonic stricturoplasty.
      • Dysplasia that cannot be removed endoscopically, multifocal dysplasia or cancer: total colectomy or proctocolectomy.
    13. 13Decision

      Is the rectum diseased?

    14. If Yes
      1. 14End

        Rectum diseased: proctocolectomy with end ileostomy

        Colon spared and no perianal disease: proctectomy with end colostomy is an option. Ileal pouch (IPAA) only in selected patients with no perianal or small bowel disease; pouch failure is higher.

      If No
      1. 15End

        Rectum spared: segmental or total colectomy

        Single segment: segmental colectomy. Extensive colitis: total colectomy with ileorectal anastomosis. Not for dysplasia or cancer: total colectomy or proctocolectomy (see colon step).

    15. Perianal
    16. 16Action

      Perianal Crohn's fistula or abscess

      • Pelvic MRI and EUA by an experienced surgeon. Check the rectum for proctitis.
      • Asymptomatic fistula: no surgery.
      • Plan surgery and medical therapy together.
    17. 17End

      Perianal: drain sepsis, place a loose seton, then biologic

      EUA: drain the abscess and place a loose draining seton. Then start or optimise anti-TNF. Repair (advancement flap or LIFT) only for a single tract with no sepsis and no proctitis. Simple low fistula with no proctitis: fistulotomy in selected patients only (risk of incontinence). Refractory disease: faecal diversion or proctectomy.

Guideline Source

ASCRS Clinical Practice Guidelines for the Surgical Management of Crohn's Disease (2020)

DOI: 10.1097/DCR.0000000000001716View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Crohn's disease recurs after resection. Plan medical therapy after surgery and ileocolonoscopy at 6 months.
  • Adults only. Children need a paediatric IBD team.
  • Perianal content follows ASCRS 2022 anorectal fistula guideline.
  • Anastomotic leak risk is higher with steroids, malnutrition, anaemia, smoking or abscess.

Contraindicated Populations

Children and adolescents under 18 years (use paediatric IBD surgical guidance)

Applicable Regions

USAUUKEU

EU: ECCO 2024 surgical treatment guideline (J Crohns Colitis 2024;18:1556-82)

UK: BSG 2019 IBD guideline

US: ASCRS 2020 Crohn's surgical guideline

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Crohn's Disease Surgical Planning Algorithm (ASCRS)?

The Crohn's Disease Surgical Planning Algorithm (ASCRS) is a management clinical algorithm for Colorectal Surgery. It provides a structured decision tree to guide clinical decision-making, based on ASCRS Clinical Practice Guidelines for the Surgical Management of Crohn's Disease (2020).

What guideline is the Crohn's Disease Surgical Planning Algorithm (ASCRS) based on?

This algorithm is based on ASCRS Clinical Practice Guidelines for the Surgical Management of Crohn's Disease (2020) (DOI: 10.1097/DCR.0000000000001716).

What are the limitations of the Crohn's Disease Surgical Planning Algorithm (ASCRS)?

Known limitations include: Crohn's disease recurs after resection. Plan medical therapy after surgery and ileocolonoscopy at 6 months.; Adults only. Children need a paediatric IBD team.; Perianal content follows ASCRS 2022 anorectal fistula guideline.; Anastomotic leak risk is higher with steroids, malnutrition, anaemia, smoking or abscess.. Individual patient factors may require deviation from these recommendations.

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