How to manage a patient with Crohn's disease (CD) and a slowly growing mesenteric mass with necrotic areas over 4 years?

Management of Mesenteric Mass in Crohn's Disease

Surgical resection of the mesenteric mass is the recommended management for this patient with Crohn's disease who has a slowly growing mesenteric mass with necrotic areas over 4 years. 1

Assessment and Diagnosis

Before proceeding with management, a thorough evaluation of the mass is essential:

1. Cross-sectional imaging:

   • CT enterography or MR enterography to characterize the mass, assess for bowel involvement, and evaluate for other complications 1, 2
   • Particular attention to presence of fistulae, abscesses, or malignancy associated with the mass

2. Laboratory evaluation:

   • Complete blood count, CRP, ESR to assess inflammatory activity 1
   • Liver function tests and albumin to evaluate nutritional status 1

Management Algorithm

Step 1: Pre-surgical Optimization

• Joint medical and surgical assessment to optimize medical therapy before surgery 1
• Nutritional support if malnourished (enteral or parenteral) 1
• Weaning of corticosteroids if possible 1
• Management of any associated abscesses with antibiotics and possible drainage 1

Step 2: Surgical Approach

• Planned elective surgery is strongly preferred over emergency surgery 1
• Deferred surgery when the patient is optimized results in lower complication rates and lower rates of stoma formation 1

Surgical Considerations:

1. Resection technique:

   • Conservative resection of the involved segment containing the mass 1
   • Resection should be limited to macroscopic disease 1
   • Midline incision is typically recommended for adequate exposure 1

2. Special considerations:

   • If strictures are present near the mass, consider strictureplasty for strictures <10 cm in length 1
   • If multiple strictures are close together, a single resection may be preferable 1
   • Primary anastomosis should be avoided in the presence of sepsis or malnutrition 1

Post-Surgical Management

1. Immediate post-operative care:

   • Monitoring of vital signs four times daily 1
   • Intravenous fluid and electrolyte replacement 1
   • Subcutaneous heparin for thromboembolism prophylaxis 1

2. Maintenance therapy:

   • Continued immunomodulatory therapy to prevent recurrence 1, 3
   • Options include:
     • Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.25 mg/kg/day) 1, 3
     • Methotrexate (15-25 mg weekly) for those who don't respond to or cannot tolerate thiopurines 3
     • Anti-TNF therapy (infliximab, adalimumab) for moderate to severe disease 1, 3

3. Monitoring for recurrence:

   • Regular follow-up with objective markers of inflammation (CRP, fecal calprotectin) 1
   • Endoscopic evaluation 6-12 months post-surgery to assess for recurrence 1

Important Considerations and Pitfalls

1. Pathological examination:

   • The resected specimen must be thoroughly examined for malignancy, particularly given the presence of necrotic areas and slow growth over 4 years 1

2. Common pitfalls to avoid:

   • Delaying surgical intervention for a progressively enlarging mass with necrotic areas
   • Performing emergency surgery without proper optimization
   • Failing to consider the possibility of malignancy in a slowly growing mass
   • Not providing appropriate post-operative prophylaxis against recurrence

3. Disease recurrence:

   • Endoscopic recurrence occurs in 30-90% of patients within 12 months of surgery 4
   • Maintenance therapy should be continued post-operatively to reduce recurrence risk 1, 3

The management of this patient requires a coordinated approach between gastroenterology and colorectal surgery. Given the presence of a slowly growing mesenteric mass with necrotic areas over 4 years, surgical resection is the most appropriate management strategy to address both potential complications from the mass and to obtain definitive pathological diagnosis.