Treatment for Crohn's Disease Flare with Small Bowel Obstruction
Surgery is mandatory for symptomatic intestinal strictures that do not respond to medical therapy and are not amenable to endoscopic dilatation in Crohn's disease with small bowel obstruction. 1
Initial Assessment and Management
Hemodynamic Stability Assessment
- Evaluate for signs of peritonitis, perforation, or bowel ischemia
- Check vital signs for:
- Tachycardia (heart rate >99 bpm)
- Hypotension
- Fever (may indicate strangulation or perforation)
- Laboratory evaluation:
- Complete blood count (elevated WBC >10,000/mm³ suggests inflammation/strangulation)
- Albumin levels (hypoalbuminemia <3.4 g/dL is a poor prognostic indicator)
- C-reactive protein (CRP values >75 may indicate peritonitis)
- Lactate levels (elevation suggests bowel ischemia)
Initial Conservative Management
For patients without signs of peritonitis, perforation, or ischemia:
- Bowel rest (NPO status)
- Intravenous fluid resuscitation
- Nasogastric tube placement for decompression
- Correction of electrolyte abnormalities
- Early surgical consultation
Medical Management
For acute Crohn's flare with partial obstruction:
- Intravenous corticosteroids (first-line for acute flares) 2
- Empiric antimicrobial therapy for patients with signs of infection
- Nutritional support (parenteral if NPO status is prolonged >5-7 days)
Surgical Management
Indications for Immediate Surgery:
- Complete obstruction not responding to conservative management
- Signs of peritonitis or perforation
- Radiological signs of pneumoperitoneum and free fluid
- Fibrotic or medically-resistant stenosis 1
- Hemodynamic instability
Surgical Approach:
- For hemodynamically stable patients: Laparoscopic approach to adhesiolysis and bowel resection (if appropriate expertise exists) 1
- For hemodynamically unstable patients: Open surgical approach 1
- Surgical options include:
- Bowel resection for fibrotic strictures
- Stricturoplasty for short strictures (<5 cm)
- Stoma creation may be necessary in high-risk patients
Decision Algorithm
Initial presentation with small bowel obstruction in Crohn's disease:
- Perform CT abdomen/pelvis with IV contrast (diagnostic accuracy >90%)
- Assess for complete vs. partial obstruction
For partial obstruction without peritonitis:
- Trial of conservative management with IV fluids, NPO, nasogastric decompression
- IV corticosteroids for active inflammatory disease
- Monitor for clinical improvement within 24-48 hours
For complete obstruction or failed conservative management:
- Surgical intervention is required
- For short strictures (<5 cm): Consider endoscopic balloon dilatation if expertise available 1
- For longer strictures or failed dilatation: Surgical resection
Important Considerations
- Percutaneous drainage should be considered as first-line treatment for abscesses >3 cm associated with Crohn's disease 1
- Any colorectal stricture should be assessed with endoscopic biopsies to ensure absence of malignancy 1
- Preoperative control of sepsis is recommended prior to abdominal surgery for Crohn's disease 1
- Patients with risk factors for anastomotic complications should receive a stoma following resection 1
Pitfalls and Caveats
- Avoid delaying surgical consultation in patients with signs of complete obstruction
- Recognize that recurrent episodes of small bowel obstruction tend to occur over time; early surgical consultation is important for interdisciplinary care 1
- Despite high initial success rates with endoscopic balloon dilatation, 73.5% of patients require re-dilatation within 24 months and 42.9% ultimately require surgical resection 1
- Avoid prolonged conservative management in patients with signs of strangulation or peritonitis, as this increases morbidity and mortality
By following this approach, patients with Crohn's disease flare and small bowel obstruction can receive appropriate, timely intervention to minimize complications and improve outcomes.