What is the best approach to manage a small bowel obstruction (SBO) in a patient with a history of Crohn's disease?

Management of Small Bowel Obstruction in Patients with Crohn's Disease

Deferred surgery is the preferred initial approach for patients with Crohn's disease presenting with acute small bowel obstruction (SBO) without evidence of bowel ischemia or peritonitis. 1

Initial Management Algorithm

1. Conservative Management (First Line)

   • Bowel rest
   • Intravenous fluid resuscitation
   • Nasogastric tube placement for decompression
   • Correction of electrolyte abnormalities
   • Early surgical consultation 1, 2

2. Medical Therapy

   • For active inflammatory disease: Intravenous corticosteroids 1, 2
   • Antibiotics only when infection is suspected or for septic complications 2

3. Monitoring for Failure of Conservative Management

   • Signs of peritonitis
   • Clinical or radiological evidence of intestinal perforation
   • Bowel ischemia
   • Persistent obstruction despite conservative measures

Management Based on Stricture Characteristics

Short Strictures (<5 cm)

• Endoscopic balloon dilatation or surgery are both suitable options 1
• Important considerations for balloon dilatation:
  • Technical success rate: 89.1%
  • Clinical efficacy: 80.8%
  • Complications (perforation/bleeding): 2.8%
  • 73.5% require re-dilatation within 24 months
  • 42.9% ultimately require surgical resection 1

Long or Multiple Strictures

• Strictureplasty is recommended when technically feasible, particularly with multiple fibrotic strictures that would require extensive bowel resection 1
• Technique selection:
  • Heineke-Mikulicz: For stenotic segments up to 6-8 cm
  • Finney and side-to-side isoperistaltic techniques: For longer or multiple strictures 1
• Benefits of strictureplasty:
  • Lower site-specific reoperation rate (7% at strictureplasty site vs 18% at anastomosis site at 10 years) 1
  • Preservation of bowel length 3

Surgical Approach When Indicated

1. Timing

   • Elective surgery is preferable to emergency procedures 1
   • Surgery is mandatory for symptomatic intestinal strictures that don't respond to medical therapy and aren't amenable to endoscopic dilatation 2

2. Technique

   • Laparoscopic approach is preferred when expertise is available (fewer complications and incisional hernias) 1
   • For fibrotic strictures: Bowel resection
   • For short strictures: Strictureplasty 2

3. Anastomosis Considerations

   • Stapled side-to-side anastomosis is superior to other configurations in terms of overall complications 1
   • Primary anastomosis may be safely performed in patients on biologic therapy (anti-TNF, vedolizumab, ustekinumab) 1
   • Consider temporary stoma if steroids cannot be withdrawn or significantly reduced prior to surgery 1

Special Considerations

1. Biologic Therapy

   • Anti-TNF therapy, vedolizumab, and ustekinumab do not appear to increase anastomotic risk 1
   • Primary anastomosis may be safely performed in patients on these medications, provided other risk factors are accounted for 1

2. Steroid Use

   • Prolonged (>6 weeks) and high-dose (≥20 mg prednisolone) steroid use increases risk of postoperative infectious complications 1
   • Consider temporary stoma if steroids cannot be withdrawn or reduced significantly 1

3. Recurrent Obstruction

   • Early recurrence (within 8 months) may indicate need for surgery 4
   • Episodes of SBO tend to recur over time; early surgical consultation is important 1

Pitfalls and Caveats

1. Avoid delayed surgical consultation in patients with signs of complete obstruction 2
2. Consider alternative etiologies for strictures in Crohn's patients, including malignancy, radiation effects, or ischemia 5
3. Recognize limitations of nasogastric decompression - associated with increased risk of pneumonia and respiratory failure in some studies 6
4. Don't delay surgery when clinical or radiological signs indicate intestinal perforation 1
5. Preoperative control of sepsis is recommended prior to abdominal surgery 1

By following this algorithm, clinicians can optimize outcomes for Crohn's disease patients with small bowel obstruction while minimizing morbidity and mortality.