Crohn's Disease
Red Flags — act before continuing history
| Red flag | Why dangerous | Action |
|---|---|---|
| Abdominal abscess (fever + mass + RIF pain) | Intra-abdominal or perianal abscess from fistulating Crohn’s can cause life-threatening sepsis. Fever + tenderness + mass in a Crohn’s patient = abscess until proven otherwise. Requires CT/MRI urgently and surgical drainage. | Same-day hospital assessment |
| Intestinal obstruction (severe colicky pain + vomiting + no flatus) | Fibrostenotic strictures in Crohn’s cause small bowel obstruction. Complete obstruction (no flatus, absolute constipation) with vomiting is a surgical emergency. Incomplete obstruction may be managed conservatively but requires hospital assessment. | 999 — surgical emergency |
| Pneumaturia or faecaluria (air/faeces in urine) | Enterovesical fistula from Crohn’s — a serious and rare complication causing recurrent urinary tract infections and systemic sepsis. Requires same-day urology and gastroenterology assessment. | Same-day urology + GI |
| Methotrexate in pregnancy | Methotrexate is a potent teratogen. Any woman of childbearing age on methotrexate who becomes pregnant or plans to conceive requires immediate withdrawal of methotrexate. Exposure in the first trimester causes miscarriage, neural tube defects, and limb defects. | Stop immediately; urgent GI + obstetrics |
| Peritonism in Crohn’s patient | Intestinal perforation can occur at any stricture point or ulcer in Crohn’s. Peritonism (guarding, rebound, rigidity) is a surgical emergency. In a known Crohn’s patient, this is perforation until proven otherwise. | 999 immediately |
| B-symptoms (night sweats, fever, weight loss) in established Crohn’s | Although constitutional symptoms are common in active Crohn’s, patients on long-term immunosuppressants have an elevated risk of lymphoma (particularly hepatosplenic T-cell lymphoma with combination azathioprine + anti-TNF). B-symptoms require urgent investigation. | Urgent haematology investigation; CT |
| Rectal bleeding + new change in Crohn’s patient ≥40 | Crohn’s is a pre-malignant condition; CRC risk is elevated. Any new rectal bleeding or change in bowel habit in an established Crohn’s patient aged ≥40 warrants consideration of CRC alongside disease activity. | Urgent colonoscopy; consider colorectal suspected cancer pathway referral |
Safeguarding Considerations — Consider in Every Consultation
🏠 Domestic Abuse and Relationship Vulnerability
- Crohn’s symptoms (urgency, perianal disease, abdominal pain) significantly affect intimacy and relationships, creating vulnerability to controlling or abusive dynamics
- Partners who undermine adherence to treatment, restrict access to healthcare, or isolate the patient from their IBD team should be considered a safeguarding concern
- Methotrexate teratogenicity means a partner coercing pregnancy against medical advice creates an immediate medical and safeguarding emergency
- Screen sensitively using SAFE questions if domestic abuse is suspected; document findings and refer per safeguarding protocol
👦 Young People and Adolescents
- Crohn’s in children causes faltering growth, delayed puberty, and significant school absence — refer to paediatric gastroenterology
- Adolescents may conceal perianal symptoms (skin tags, fistulae) due to embarrassment, leading to delayed diagnosis and complications
- Body image issues from steroid-induced weight gain, abdominal scars, and stoma (if colectomy) are particularly severe in adolescents and require specialist psychological support
- Transition from paediatric to adult IBD services is a high-risk period for non-adherence; GP has a key role in supporting this transition
💊 Immunosuppression and Infection Risk
- Azathioprine, methotrexate, and biologics cause significant immunosuppression; patients must be counselled about infection risk and instructed to seek same-day assessment for fever
- Opportunistic infections (PCP, CMV, atypical mycobacteria) are rare but life-threatening in immunosuppressed Crohn’s patients; maintain a low threshold for investigation
- Varicella (chickenpox) exposure in an immunosuppressed Crohn’s patient requires urgent risk assessment for post-exposure prophylaxis — oral aciclovir or valaciclovir from day 7 to 14 after exposure, with VZIG only if antivirals are contraindicated (UKHSA PEP guidance, February 2025); check VZV serology before starting any immunosuppressant
- Document vaccination status before every new immunosuppressant; live vaccines contraindicated while on immunosuppression
🚬 Methotrexate and Reproductive Safeguarding
- Methotrexate is a teratogen requiring effective contraception for all patients of childbearing potential (per current product information)
- Document contraceptive status at every methotrexate review; folic acid 5 mg once weekly (on a different day from methotrexate) must be co-prescribed
- If a patient on methotrexate becomes pregnant: stop methotrexate immediately, urgent GI + obstetric referral same day; do not delay
- Men and women on methotrexate: follow the specialist team for contraception and pre-conception planning. BSR advises stopping 1 month before conception for women and no routine stop for men on ≤25 mg/week; the SPC and some IBD guidance are more cautious.
💃 Education and Career
Crohn’s significantly impairs educational performance and career progression. Students may miss exams during flares; employees may miss work frequently. Crohn’s is a disability under the Equality Act 2010.
“Has this been affecting your work or your studies? I can write a letter to support reasonable adjustments — including toilet access and flexible working. This is your legal right under the Equality Act.”🚬 The Smoking Conversation
Smoking is the single most important modifiable risk factor for Crohn’s disease. Many patients are not told this clearly. Framing smoking cessation as the most effective “drug” for Crohn’s — more effective than many medications — is the most motivating approach.
“I want to tell you something that often changes how patients think about smoking: it is probably the single most effective thing you can do for your Crohn’s disease. Smoking is linked to more flares, more recurrence after surgery and more operations — stopping genuinely improves Crohn’s.”💑 Body Image and Relationships
Perianal disease, stoma possibility, steroid-related weight gain, and abdominal scars profoundly affect body image and intimate relationships. Patients frequently do not disclose these concerns without direct, sensitive enquiry.
“Crohn’s can be really hard on your sense of yourself and your relationships — there are things like skin changes, the worry about operations, and the unpredictability. Is that something that has been affecting you?”💐 Family Planning and Methotrexate
Methotrexate is a teratogen requiring effective contraception, and before conception, follow the specialist team: BSR advises stopping 1 month before conception for women and no routine stop for men on ≤25 mg/week; the SPC and some IBD guidance are more cautious. Many patients are not aware of this or have not had the conversation. Active contraception check at every methotrexate review is mandatory.
“Are you thinking about starting a family in the future? I ask because the methotrexate you are on requires careful planning — we need to plan with your specialist team before you try to conceive, and we need to be sure you have effective contraception in the meantime.”🧠 Diagnostic Delay and Trust
The average diagnostic delay in Crohn’s is 3–5 years from symptom onset. Patients who have been told they have IBS for years before the correct diagnosis is made often arrive with justifiable frustration, distrust, and sometimes anger. Acknowledging this directly is the first step in rebuilding the therapeutic relationship.
“I can hear how frustrating it must have been to feel unwell for so long without a clear answer. That is really hard, and I want to make sure we do the right investigation now, rather than repeating the same approach.”📈 Fear of Surgery and Stoma
Surgery is required in 70–80% of Crohn’s patients within 20 years, and stoma is a real possibility for some. Fear of surgery and particularly stoma shapes patients’ engagement with treatment — they may resist escalation of therapy to avoid the topic. Accurate information and specialist support are essential.
“Are you worried about the possibility of needing an operation or a stoma? This is something many patients are frightened about — I want to give you accurate information rather than leaving that fear in the background.”- Not asking about perianal symptoms — the most specific question in suspected Crohn’s
- Not asking about smoking — the single most important modifiable risk factor
- Accepting the previous IBS label without active exclusion of organic pathology
- Prescribing NSAIDs for abdominal pain in a patient with suspected or confirmed Crohn’s
- Not checking contraception status in a woman of childbearing age on methotrexate
Same-Day Hospital / 999
Act immediately- Intestinal obstructionSevere colicky pain + vomiting + no flatus → 999; IV fluids; surgical assessment; NG tube if vomiting
- Intra-abdominal abscess (fever + mass + pain)Fever + localised tenderness + peritonism → same-day hospital; CT/MRI + surgical drainage
- Peritonism or perforationGuarding, rebound, rigidity → 999; IV access + antibiotics; surgical emergency
- Methotrexate in pregnancy (any trimester)Stop methotrexate immediately; same-day GI + obstetrics; teratogen emergency
- Enterovesical fistula (pneumaturia, faecaluria)Same-day urology + GI; risk of ascending sepsis; IV antibiotics
Urgent Specialist Input
Days to 2 weeks- First presentation of suspected Crohn’sPerianal disease, weight loss, RIF pain, raised calprotectin → urgent GI referral for colonoscopy + small bowel imaging
- Perianal abscess (painful, fluctuant swelling)Contact colorectal surgery same day — requires incision and drainage; do not prescribe antibiotics alone
- Severe Crohn’s flare (systemically unwell, significant weight loss)Contact IBD nurse specialist; FBC + CRP + calprotectin; admit if haemodynamically compromised
- Sub-acute obstruction (partial, intermittent)Same-day gastroenterology/surgical assessment; imaging arranged by the specialist team; no steroid until complications assessed; low-residue diet
- Flare not clearly improving within a few days of steroidsSpecialist reassessment (not dose escalation); exclude abscess/infection; immunomodulator/biologic step-up
- New extraintestinal manifestation (uveitis, pyoderma gangrenosum)Same-day ophthalmology (uveitis); urgent dermatology (PG); continue Crohn’s management
Primary Care / IBD Nurse
GP practice- Mild Crohn’s flare in established patientContact IBD nurse specialist; review adherence; consider oral prednisolone; stool cultures first
- Annual Crohn’s reviewBlood monitoring; smoking cessation check; surveillance scope date; vaccination update; mental health screen
- Azathioprine or methotrexate monitoringFBC + LFTs per schedule; contraception check (methotrexate); check allopurinol co-prescription
- Smoking cessation referralEvery consultation — refer to stop smoking service; offer pharmacotherapy; document advice given
- Nutritional supplementationIron, vitamin D, folate, B12 as indicated; dietitian referral for malnutrition or restrictive eating
- Treating a perianal abscess with antibiotics alone without surgical referral for incision and drainage
- Not recognising intestinal obstruction (colicky pain + vomiting + no flatus) as a surgical emergency
- Missing methotrexate in pregnancy as an immediate medical emergency
- Prescribing NSAIDs for pain relief in suspected or known Crohn’s disease
- Not performing perianal inspection in suspected or established Crohn’s disease
- Missing a perianal abscess (palpable, tender, fluctuant swelling) and not referring for drainage
- Attempting to debride a skin lesion that may be pyoderma gangrenosum
- Not examining the eyes in a Crohn’s patient complaining of red eye
- Accepting a previous normal colonoscopy as excluding Crohn’s without small bowel imaging
- Starting azathioprine without TPMT enzyme testing
- Not ordering faecal calprotectin when IBD is in the differential
- Not ordering B12 in ileal Crohn’s (terminal ileum is the exclusive B12 absorption site)
“What you have is called Crohn’s disease. It is an autoimmune condition — your immune system is attacking your digestive system and causing inflammation throughout it. Unlike another condition called colitis, Crohn’s can affect any part of the digestive tract, from your mouth all the way to your bottom, and it tends to go through the full thickness of the bowel wall rather than just the surface. This is why it can sometimes cause complications like narrowings, abnormal connections between different parts of the gut, and problems around the back passage. It is a long-term condition that tends to flare up and then settle down. The good news is that with the right treatment — and importantly, stopping smoking if you smoke — most people lead full, normal lives.”
“My previous GP told me this was IBS. How can it be Crohn’s now?”
“I completely understand why that is confusing and frustrating. IBS and Crohn’s can look similar in terms of symptoms — both cause abdominal pain and diarrhoea. But there are key differences: Crohn’s causes inflammation that shows up in blood tests and a stool test, and the weight loss and skin tags you have around your bottom are not features of IBS. It is quite possible that Crohn’s was there all along but was not recognised early. I am sorry that it has taken this long to get to the right diagnosis.”
“I am worried this is cancer — the weight loss really frightens me.”
“I completely understand why the weight loss is frightening — it is something that needs to be investigated urgently and I am taking it seriously. The picture you describe with the right-sided pain, the bowel symptoms, and the skin tags around the back passage is much more consistent with Crohn’s disease than cancer. We will do the right investigation to confirm this — and you will have an answer much sooner than you think.”
Crohn’s Disease — Inflammatory (B1)
Active transmural inflammation; no complications (stricture or fistula yet); typically responds to steroids; aim for remission with immunomodulator maintenance.
Crohn’s Disease — Stricturing (B2)
Fibrostenotic narrowing causing obstructive symptoms; may require stricturoplasty or resection; balloon dilatation for short strictures.
Crohn’s Disease — Fistulating (B3)
Transmural inflammation penetrating to form fistulae (perianal, enterocutaneous, enterovesical, rectovaginal); combined medical (anti-TNF) + surgical management.
Ulcerative Colitis
Mucosal (not transmural); continuous from rectum; no skip lesions; no perianal disease; no small bowel involvement; no granulomas; 5-ASA effective (unlike Crohn’s); methotrexate less evidence.
Irritable Bowel Syndrome (mislabelled)
Normal inflammatory markers; normal calprotectin (a low result does not exclude small-bowel Crohn’s); no weight loss; no perianal disease; no granulomas. Many Crohn’s patients are labelled as IBS for years. Always check calprotectin before IBS diagnosis.
Intestinal Tuberculosis
Transmural granulomatous inflammation mimicking Crohn’s on biopsy; always screen for TB (Mantoux, IGRA, CXR) before starting anti-TNF biologics — risk of fatal TB reactivation.
Appendicitis (acute RIF pain)
Acute onset, fever, WBC; Crohn’s terminal ileitis can mimic appendicitis clinically; CT distinguishes; do not delay appendicitis treatment pending IBD diagnosis.
Intra-abdominal Abscess
Fever + RIF mass + tenderness; CT confirms; requires drainage (IR-guided or surgical) + antibiotics; do not rely on antibiotics alone.
Small Bowel Obstruction
Colicky pain + vomiting + distension + no flatus; plain AXR + CT; NGT decompression; surgical or endoscopic management depending on aetiology.
Lymphoma (rare, immunosuppression-related)
Hepatosplenic T-cell lymphoma (HSTCL) associated with combination azathioprine + anti-TNF in young men; B-symptoms; urgent haematology investigation.
- Not addressing the cancer fear directly with specific reassurance and a plan
- Not distinguishing Crohn’s from UC in terms of clinical and treatment implications
- Not addressing the diagnostic delay and the patient’s frustration with empathy
- Not emphasising smoking cessation as the most effective modifiable intervention
- Initiating biologic therapy without TB screening (fatal TB reactivation risk)
- Not referring a perianal abscess for same-day surgical drainage
- Missing the smoking cessation referral in a smoking Crohn’s patient
- Prescribing methotrexate without folic acid co-prescription or contraception check
Validate — the desire for a cure or natural management
Many Crohn’s patients come with a strong desire for a dietary cure or to avoid immunosuppressants. After years of diagnostic delay, they may have already tried many dietary approaches and feel sceptical about medication. Acknowledging this history validates their experience and builds trust.
“I can understand why, after so long without an answer, you might want to try diet and lifestyle changes first. Let me explain what the evidence shows — and what I think gives you the best chance of controlling this properly.”Explain — why medication is needed alongside lifestyle
Crohn’s disease causes structural damage (strictures, fistulae, abscesses) that cannot be prevented by diet alone. The inflammatory process requires active suppression to prevent progressive bowel damage that eventually requires surgery. Diet supports but does not replace medical treatment.
“The inflammation in Crohn’s causes actual structural damage to the bowel over time — scarring, narrowings, and abnormal connections. Medication is what prevents that damage from accumulating. Diet makes a real difference, but it cannot stop this process on its own.”Negotiate — offer smoking cessation as the most powerful lifestyle intervention
If the patient smokes, this is the concrete, evidence-based lifestyle intervention that genuinely changes the disease course. Framing it as the most effective “natural” intervention — more effective than diet — is a compelling bridge between the patient’s expectations and the clinical evidence.
“Here is what I know will genuinely make a difference: stopping smoking. It is more effective for Crohn’s disease than many medications we have available. If that is the one thing we focus on today, alongside proper treatment, I think you will see a real difference.”Smoking is associated with more active Crohn’s disease, relapse, postoperative recurrence and surgery (the opposite of UC). Stopping is a key part of preventing relapse and recurrence after resection.
Brief advice at every consultation (document this). Refer to NHS Stop Smoking Service. Offer behavioural support plus varenicline, cytisinicline, combination NRT (patch + lozenge) or a nicotine vape — the options NICE NG209 rates most likely to work. Frame cessation as “the most effective treatment we have for Crohn’s disease.”
Exclusive enteral nutrition (EEN) with elemental or polymeric feeds induces remission in 60–80% of children with Crohn’s and is first-line in paediatric Crohn’s. In adults, BSG 2025 finds insufficient evidence for routine EEN — it is used only in selected circumstances, as a specialist and dietitian decision. It also corrects malnutrition concurrent with its anti-inflammatory effect.
Dietitian referral for all Crohn’s patients. Ensure adequate caloric and protein intake during flares. No specific exclusion diet has strong evidence in Crohn’s remission. Avoid unnecessary dietary restriction without dietitian guidance.
Psychological stress activates the HPA axis and sympathetic nervous system, increasing intestinal permeability and triggering mucosal inflammation. Stress is a recognised precipitant of Crohn’s flares through neuroimmunological mechanisms.
Mindfulness-based stress reduction (MBSR), CBT, and gut-directed hypnotherapy all have evidence in IBD. Peer support (Crohn’s & Colitis UK). PHQ-9 and GAD-7 annually. NHS Talking Therapies referral for anxiety and depression.
Regular moderate exercise reduces inflammatory cytokine levels, improves bone mineral density (particularly important given steroid use), and significantly improves mental health and fatigue in Crohn’s patients. Intense exercise may worsen symptoms during active disease.
150 minutes/week moderate activity in remission. Rest during flares. Yoga has specific evidence for IBD (physical + stress reduction combination). RADAR key for accessible toilet access. Physiotherapy for musculoskeletal complications.
NSAIDs disrupt gut mucosal prostaglandin synthesis and are recognised Crohn’s flare triggers. The risk of GI complications from NSAIDs is substantially higher in Crohn’s than in the general population. Patients frequently take OTC NSAIDs for arthropathy (a common EIM) — ask specifically.
Paracetamol for analgesia. Topical NSAIDs (where local action only is needed) are preferable to systemic. If NSAID is unavoidable for comorbidity: COX-2 inhibitor with specialist GI advice. Document NSAID avoidance advice at every consultation.
Before any immunosuppressant: VZV serology (varicella vaccine if non-immune, ≥4 weeks before starting); hepatitis B series; pneumococcal; HPV per JCVI schedule. TB screen (IGRA or Mantoux + CXR) is mandatory before any anti-TNF biologic. Annual influenza and COVID-19 boosters throughout.
Live vaccines (MMR, varicella, yellow fever) are generally contraindicated during significant immunosuppression; timing depends on the drug and any treatment interruption — check the Green Book and discuss with the IBD team. Give needed live vaccines before starting where feasible (at least 4 weeks). Document vaccination status at every immunosuppressant review.
- Budesonide (specialist-directed; course per product information): Consider for mild-to-moderate ileal or ileocaecal Crohn’s when systemic corticosteroids are unsuitable, declined or not tolerated (NICE NG129) — less effective; first-pass hepatic metabolism reduces systemic steroid side effects; not effective in colonic disease
- Prednisolone (first-line induction): Dose, duration and taper per the patient’s IBD flare plan or local protocol, documented; early review — not improving within a few days → specialist reassessment, not dose escalation; calcium/vitamin D when indicated
- Exclusive enteral nutrition (EEN): Children: preferred over steroids for inducing remission; Adults: only in selected circumstances — specialist and dietitian decision (BSG 2025)
- 🔴 Stool cultures (C. difficile toxin) before any steroid course — mandatory
- Azathioprine 2–2.5mg/kg/day: First-line immunomodulator; TPMT testing mandatory; takes 3–6 months to work; FBC + LFTs monthly ×3, then 3-monthly; check allopurinol (major drug interaction)
- Methotrexate 15–25mg SC weekly: Alternative to azathioprine; particularly useful when azathioprine is not tolerated; folic acid 5 mg once weekly mandatory (different day from methotrexate); LFTs monthly; effective contraception mandatory
- 6-Mercaptopurine (6-MP): Alternative to azathioprine if nausea is the intolerance (NOT for azathioprine-induced pancreatitis)
- Note: 5-ASA has weaker evidence in Crohn’s than UC; mesalazine is not standard maintenance for Crohn’s (unlike UC)
- Anti-TNF agents (infliximab IV / adalimumab SC): For moderate-to-severe Crohn’s not responding to immunomodulators; also first-line for fistulating disease; TB + hepatitis B screen mandatory before starting
- Vedolizumab (gut-selective): Less immunosuppression; safer infection profile; preferred in elderly or those with prior infections
- Ustekinumab (IL-12/23 inhibitor): For Crohn’s not responding to anti-TNF; also treats psoriasis (useful in patients with skin EIMs)
- GP monitoring role: infection surveillance; annual influenza + COVID-19 vaccine; skin cancer screening; no live vaccines; shared care monitoring
- 70–80% of Crohn’s patients require surgery within 20 years; surgery is not curative (unlike UC) because Crohn’s can recur at anastomotic sites
- Post-surgical recurrence: endoscopic recurrence within 1 year in 70%; clinical recurrence in 50% at 5 years; early post-operative anti-TNF significantly reduces recurrence
- Perianal fistulae: seton suture (surgical drain) + anti-TNF biologic combination is the gold standard; MRI pelvis before any perianal surgery
- Stricturoplasty: bowel-conserving surgery for fibrostenotic strictures; preferable to repeated resection in patients with short bowel
- GP role: pre-operative nutritional optimisation; post-operative anti-TNF monitoring; stoma care support; psychological preparation
- 🔴 Folic acid 5 mg once weekly mandatory co-prescription (taken on a different day from methotrexate)
- 🔴 Effective contraception mandatory in all patients of childbearing potential (per current product information)
- 🔴 Alcohol contraindicated (additive hepatotoxicity risk)
- 🔴 Stop before planned conception (men and women) — interval per current product information and specialist advice
- 🔴 Live vaccines contraindicated while on methotrexate
- Monitoring: FBC + LFTs monthly; DLCO (lung function) if pulmonary symptoms develop (methotrexate pneumonitis)
- Methotrexate pneumonitis: cough + dyspnoea + fever on methotrexate → stop immediately; urgent chest X-ray; respiratory assessment
- Ileal / ileocaecal disease (L1/L3)
- Colonic disease (L2)
- Fistulating disease (B3)
- Active smoker
- Pregnant or planning pregnancy
Colonic (L2): Prednisolone per IBD flare plan; 5-ASA not effective maintenance; AZA or methotrexate for maintenance
Fistulating (B3): Anti-TNF biologic (infliximab/adalimumab) + seton suture; MRI pelvis for mapping
Active smoker: Smoking cessation is the FIRST and MOST EFFECTIVE intervention; refer to stop smoking service
Pregnant: Stop methotrexate immediately; continue azathioprine if high disease risk (specialist decision); mesalazine safe
“This steroid works mainly in the part of the bowel that is most affected by your Crohn’s, and most of it is processed by the liver before reaching the rest of the body. This means it has fewer side effects than the steroids most people know about. Take it in the morning as a whole capsule.”
SCA pearl: NICE NG129 makes a conventional steroid the first-line induction; budesonide is a specialist-directed option for ileocaecal disease when systemic steroids are unsuitable, declined or not tolerated — it is less effective. Never use budesonide for colonic disease — this is a scored error.
“This medication needs to be taken once a week — not every day. The folic acid tablet is also taken once a week, on a different day from the methotrexate. You must not drink alcohol while on it, and contraception is absolutely essential. If you develop a cough or feel breathless in the next few months, please come back immediately.”
SCA pearl: Three things always score for methotrexate in the SCA: (1) folic acid 5 mg once weekly co-prescription (different day from MTX); (2) contraception check and documentation; (3) alcohol contraindication. Missing any of these is a scored omission. Methotrexate pneumonitis is a rare but serious complication — mentioning it demonstrates clinical depth and scores in Tasks domain.
“This medication directly targets the inflammatory protein that is causing the Crohn’s. It is very effective, but because it works on the immune system, it is important that you come to us promptly if you develop a fever or any signs of infection. You should also not receive any live vaccines while on this treatment.”
SCA pearl: TB screening before anti-TNF is the single most important pre-biologic action and is a scored clinical requirement. Fatal cases of TB reactivation have occurred when anti-TNF was started without screening. Also: hepatitis B reactivation and live vaccine contraindication should be mentioned for a full Tasks score. The GP’s monitoring role under shared care demonstrates system-level knowledge.
“This tablet reduces your immune system’s activity to keep the Crohn’s under control. It takes 3–6 months to reach its full effect. You will need regular blood tests throughout. If you develop a fever or feel very unwell, please contact us the same day — infections need prompt treatment when you are on this medication.”
SCA pearl: The same scoring items apply as in UC: TPMT before starting; FBC + LFTs per schedule; allopurinol interaction check. The key difference in Crohn’s: azathioprine is often combined with anti-TNF biologic therapy (combination therapy), and the combination with anti-TNF increases the risk of HSTCL lymphoma in young men — documenting awareness of this rare risk demonstrates exceptional clinical knowledge.
Work, Education, and Legal Rights
Crohn’s is a disability under the Equality Act 2010. Employers must make reasonable adjustments including unrestricted toilet access, flexible working during flares, and time for appointments. Students with Crohn’s have rights to exam accommodations and extended deadlines.
GP letter to employer or educational institution; fit notes during flares; occupational health referral; PIP assessment support if indicated.
“You have legal rights as someone with Crohn’s disease — your employer must allow you unrestricted toilet access and make other reasonable adjustments. I can write a supporting letter explaining your medical situation if that would help.”Smoking and Crohn’s Disease
Smoking is associated with more flares, more surgery and more post-surgical recurrence. It is the single most important modifiable risk factor. Many patients do not realise the magnitude of this association. Framing smoking cessation as the most effective “drug” for Crohn’s is highly motivating for patients who are reluctant to take medication.
Brief advice at every consultation; stop smoking service referral; document advice given; offer pharmacotherapy.
“Stopping smoking is more effective for your Crohn’s disease than many of the medications I can offer. It means fewer flares and less chance of needing surgery. That makes it the most important thing we can do for your Crohn’s today.”Surgery Fear and Realistic Information
70–80% of Crohn’s patients require surgery within 20 years — but surgery in Crohn’s is increasingly bowel-sparing (stricturoplasty) and is not curative. Fear of surgery and stoma shapes treatment decisions and engagement. Accurate, compassionate information reduces fear-driven non-adherence to treatment.
Address surgical fear proactively; IBD nurse specialist for specialist discussions; stoma nurse referral if surgical pathway approaches.
“Surgery for Crohn’s is increasingly common and the techniques have improved enormously. Many operations now preserve the bowel and most people do not need a permanent stoma. I want to give you accurate information so that fear of surgery is not driving our decisions.”Family Planning — Methotrexate Safety
Methotrexate is a mandatory teratogen. Effective contraception is required for all patients of childbearing potential while on methotrexate, and before conception, follow the specialist team: BSR advises stopping 1 month before conception for women and no routine stop for men on ≤25 mg/week; the SPC and some IBD guidance are more cautious.
Active contraception check at every methotrexate review; document clearly; folic acid confirmed; GI + obstetric co-management when pregnancy is planned.
“I need to check your contraception at every review while you are on methotrexate — it is one of the most important medicines we use for Crohn’s but it is not safe in pregnancy and we need to plan very carefully if a pregnancy is something you are thinking about.”Mental Health and Diagnostic Frustration
The average diagnostic delay in Crohn’s disease is 3–5 years. By the time of diagnosis, many patients have significant accumulated frustration, distrust of the healthcare system, and depression from years of unrecognised suffering. Acknowledging this directly is therapeutically necessary before any clinical plan can be received.
PHQ-9 and GAD-7 at every annual review; NHS Talking Therapies referral; Crohn’s & Colitis UK peer support; specialist IBD psychology where available.
“I can hear how much you have been through to get to this point. Years of symptoms without an answer, being told it was IBS — that is a really significant thing to have experienced. I am genuinely sorry it took this long.”Body Image and Perianal Disease
Perianal disease (fistulae, skin tags, abscesses) profoundly affects body image, sexual function, and intimate relationships. Many patients are too embarrassed to disclose perianal symptoms to any clinician, leading to delayed diagnosis and treatment of complications.
Create a non-judgmental space for perianal symptom discussion; direct questioning at every Crohn’s review; refer to IBD nurse for specialist psychosocial perianal support; stoma nurse if indicated.
“I want to ask directly about symptoms around the back passage — I know it is not easy to talk about, but it is medically important and completely normal to have these as part of Crohn’s disease. You are not alone in experiencing this.”48–72 hours, then 1–2 weeks — Acute flare review
Review steroid response; confirm stool culture results; smoking cessation status; perianal symptom check; contact IBD nurse to update. Phone review at 48–72 hours; not clearly improving within a few days → same-day specialist reassessment, not dose escalation. Face-to-face review at 1–2 weeks. Check calprotectin trend.
3 months — Remission check
Clinical remission confirmed; calprotectin trending to normal (local threshold); azathioprine or methotrexate monitoring bloods; TPMT confirmed; contraception checked (methotrexate); perianal disease status; dietary and nutritional review; smoking status update.
6 months — Stability review
FBC + CRP + LFTs + albumin + vitamin D + iron studies + B12. Azathioprine monitoring 3-monthly. Methotrexate monitoring monthly. PHQ-9/GAD-7. NSAID avoidance confirmed. Cancer surveillance scope date confirmed if relevant. Smoking cessation progress.
Annual review — GP-led Crohn’s review
FBC + CRP + calprotectin + LFTs + albumin + vitamin D + iron studies + B12 + folate. Azathioprine monitoring. Methotrexate: contraception check + LFTs. Vaccination update. Skin cancer check. Smoking status. NSAID avoidance. PHQ-9/GAD-7. Cancer surveillance scope if relevant (colonic Crohn’s >8–10 years). GI outpatient confirmed.
Open access — complications at any time
Urgent: perianal abscess (same-day surgical referral); intestinal obstruction (999); fever on immunosuppressants (same-day assessment); red eye or visual change (same-day ophthalmology); methotrexate pregnancy (stop immediately + same-day GI + obstetrics). Contact IBD nurse specialist for most flares in established patients before attending ED.
Annual Crohn’s review checklist
Bloods: FBC (anaemia, myelosuppression) · CRP (disease activity) · Calprotectin (mucosal inflammation) · LFTs + albumin (drug toxicity; nutrition) · Vitamin D (nearly universal deficiency) · Iron + B12 + folate (malabsorption) · Immunosuppression monitoring: AZA: FBC + LFTs 3-monthly · MTX: FBC + LFTs monthly; contraception at every review · Safety: TB screen before anti-TNF · HBV serology before anti-TNF · Vaccination update · Skin cancer check · NSAID avoidance · Smoking cessation · Mental health: PHQ-9/GAD-7 annually · Perianal: Ask at every consultation (direct questioning required)
⚠ Three scenario-specific phrases — use these verbatim
Why safety-netting matters beyond clinical care
- Not mentioning smoking cessation in a smoker with Crohn’s at close of consultation
- No closing question for remaining concerns
- Methotrexate safety not summarised (contraception + folic acid + alcohol)
- Not giving specific A&E trigger criteria (abscess, obstruction)
- Perianal symptoms specifically asked about and findings acted on
- Smoking cessation offered at every consultation and documented
- TPMT before AZA; folic acid + contraception with methotrexate
- TB screen + HBV serology before anti-TNF stated
- B12 monitoring in ileal disease discussed
- Diagnostic delay acknowledged with empathy; previous IBS label challenged
- Cancer fear specifically addressed with evidence and plan
- Smoking framed as most effective Crohn’s intervention (not just health advice)
- Surgery/stoma fear addressed with accurate and compassionate information
- Plan negotiated and agreed; patient’s agency respected
- Closing question asked
Who you are
Jamie, 26 years old, works as a scaffolder. Has been a smoker of 15 cigarettes a day for 6 years. Has had right iliac fossa (RIF) pain for 8 months, 4–5 loose non-bloody stools per day, has lost 7 kg over 6 months without trying. Also has some skin tags around the back passage that are occasionally uncomfortable but has never mentioned them to a doctor. Has mouth ulcers intermittently — has assumed they are stress-related. Had a normal colonoscopy 5 months ago (does not know the terminal ileum was not reached). Has been told this is IBS.
Hidden agenda and ICE
Terrified of cancer. Brother had testicular cancer at 24 and he thinks weight loss always means cancer. Worried the normal colonoscopy means doctors cannot find what is wrong, not that there is nothing wrong. Embarrassed about the skin tags and will not mention them unless specifically asked about the back passage. Wants to know definitively what is wrong, not just another diet suggestion. Is sceptical about medication but open to it if the reason is explained clearly.
Symptoms if asked directly
- RIF pain: constant background ache, worse after eating; crampy at times
- Stool frequency: 4–5 loose stools/day; not bloody; wakes once at night to go
- Perianal symptoms: 2–3 skin tags present; occasionally uncomfortable; no abscess
- Mouth ulcers: recurrent, 2–3 per month; inside cheeks
- Weight loss: 7 kg over 6 months; appetite reduced as eating worsens pain
- Smoking: 15 cigarettes/day for 6 years; has tried to stop once with no success
- No fever currently; no joint pains; no eye symptoms
- Normal colonoscopy 5 months ago (terminal ileum NOT reached — does not know this)
Bonus details and resolution
- Perianal skin tags: only discloses if directly and sensitively asked about symptoms around the back passage
- Mouth ulcers: discloses freely if asked about other symptoms; “I get a lot of mouth ulcers too”
- Smoking: defensive initially but receptive to Crohn’s-specific framing (“most effective treatment”)
- Challenge phrase: “But the colonoscopy was normal — surely that means it is not Crohn’s?”
- Resolution: accept urgent GI referral if clinician explains why the previous scope was incomplete and what additional imaging is needed; remains anxious about cancer — only reassured by a specific investigation plan, not by generic reassurance
Resolution: Accept the explanation if the clinician clearly explains: (1) that a normal colonoscopy does not exclude Crohn’s because the small bowel (which is where the disease most often starts) cannot be visualised by colonoscopy; (2) that MRI small bowel imaging is needed to assess the area most likely to be affected; (3) that the perianal skin tags and mouth ulcers together with the weight loss and right-sided pain form a pattern consistent with Crohn’s. Do NOT accept “the colonoscopy might have missed something” as an adequate explanation — the clinician must specifically mention small bowel imaging. Cancer fear must be addressed with a specific plan, not reassurance alone.
- Intestinal obstruction → 999
- Perianal abscess → same-day surgical referral
- Peritonism / perforation → 999
- Methotrexate + pregnancy → stop immediately; GI + obstetrics today
- Enterovesical fistula → urology + GI same day
- First presentation (perianal / weight loss / raised calprotectin)
- Moderate/severe flare → IBD nurse same day
- Suspected obstruction → same-day GI/surgical assessment
- New EIM (uveitis same day; PG urgent dermatology)
- Not improving within a few days of steroids → urgent specialist reassessment
- Mild flare → IBD nurse; stool cultures; review adherence
- Annual review → bloods + smoking + vaccinations + mental health
- Immunomodulator monitoring
- Smoking cessation → every consultation
- Nutritional supplementation
🔴 Methotrexate: folic acid 5 mg once weekly mandatory (different day from MTX)
🔴 Methotrexate: effective contraception mandatory
🔴 Methotrexate: alcohol absolutely contraindicated
🔴 Anti-TNF: TB screen + HBV serology mandatory first
🔴 Azathioprine: TPMT enzyme test mandatory first
🔴 Allopurinol + azathioprine: 75% dose reduction required
🔴 NSAIDs: avoid regular/high-dose; if essential, lowest dose for shortest time with IBD advice
🔴 Perianal abscess: surgical drainage; never antibiotics alone
✅ Stool cultures before every steroid course
✅ Smoking cessation at every consultation — document this