What is the best course of treatment for a patient with a history of Crohn's disease (CD) presenting with severe abdominal pain, bloating, sulfurous belching, and loose stools?

Management of Crohn's Disease Exacerbation with Severe Abdominal Pain and GI Symptoms

A multidisciplinary approach involving both a gastroenterologist and acute care surgeon is required for this Crohn's disease patient presenting with severe abdominal pain, bloating, sulfurous burps, and loose stools, with immediate evaluation for intra-abdominal abscess formation as the most likely cause of symptoms. 1

Initial Assessment and Diagnostic Workup

• Immediate evaluation for intra-abdominal abscess is crucial as the symptoms strongly suggest possible abscess formation or superinfection
• Obtain:
  • Complete blood count, inflammatory markers (CRP, ESR)
  • Electrolytes, liver function tests
  • Stool sample for culture and C. difficile toxin assay 1, 2
• Imaging:
  • CT enterography as first-line imaging to assess for abscess formation
  • Alternatively, MR enterography if available (similar accuracy without radiation) 1

Treatment Algorithm

If Abscess is Detected:

1. For abscess >3 cm:

   • Percutaneous drainage under radiological guidance
   • Early empiric antimicrobial therapy against gram-negative aerobic/facultative bacilli, gram-positive streptococci, and obligate anaerobic bacilli
   • Adjust antibiotics based on culture results 1

2. For abscess <3 cm:

   • Intravenous antibiotics with close clinical and biochemical monitoring
   • Be aware of higher risk of recurrence, especially if associated with enteric fistula 1

3. Consider surgery if:

   • Percutaneous drainage fails
   • Patient develops signs of septic shock
   • Enteric fistulae are present
   • Clinical evidence of sepsis persists despite initial treatment 1

If No Abscess is Detected (Inflammatory Flare):

1. For moderate to severe Crohn's disease flare:

   • Intravenous corticosteroids if patient is hemodynamically stable 1
   • Assess response by the third day 1

2. For non-responders who remain hemodynamically stable:

   • Consider medical rescue therapy with infliximab in combination with a thiopurine 1, 3
   • Infliximab is particularly effective for penetrating ileocecal Crohn's disease after adequate resolution of intra-abdominal abscesses 1

3. Supportive care:

   • Adequate intravenous fluid resuscitation
   • Low-molecular-weight heparin for thromboprophylaxis
   • Correction of electrolyte abnormalities and anemia 1, 2

Important Considerations and Pitfalls

• Do not routinely administer antibiotics unless superinfection is suspected or an abscess is present 1
• Avoid delaying surgical intervention in patients with peritonitis or hemodynamic instability as this increases morbidity and mortality 2
• Be cautious with immunomodulators and anti-TNF-α agents in patients who may require emergency surgery, as these increase risk of intra-abdominal sepsis 1
• Monitor for serotonin syndrome if combination gut-brain neuromodulators are used for pain management 1
• Avoid opioid prescribing when possible to prevent iatrogenic harm 1

Follow-up Management

• After acute management, consider maintenance therapy with immunomodulators (azathioprine, 6-mercaptopurine) or biologics (infliximab) 1, 3
• For patients with severe or refractory symptoms, an integrated multidisciplinary approach is essential 1
• Regular monitoring of inflammatory markers to assess disease activity and treatment response
• Consider nutritional support in severely undernourished patients 1

This approach prioritizes prompt diagnosis and treatment of potential abscess formation or inflammatory flare in a patient with Crohn's disease, with the goal of reducing morbidity and mortality through appropriate antimicrobial therapy, drainage procedures when indicated, and timely surgical intervention if necessary.