What is the strongest indication for surgery in a patient with a long history of Crohn’s disease (Crohn's disease, CD)?

Intestinal Obstruction is the Strongest Indication for Surgery in Crohn's Disease

The strongest indication for surgery in a 30-year-old man with a long history of Crohn's disease is intestinal obstruction (option C). This is supported by multiple high-quality guidelines that consistently identify intestinal obstruction as a primary surgical indication in Crohn's disease.

Primary Indications for Surgery in Crohn's Disease

Intestinal Obstruction

• Surgery is mandatory for symptomatic intestinal strictures that do not respond to medical therapy and are not amenable to endoscopic dilatation 1
• Strong recommendation to perform surgery in patients presenting with small bowel obstruction due to fibrotic or medically-resistant stenosis 1
• Surgery is the preferred option in patients with localized ileocecal Crohn's disease with obstructive symptoms, particularly when there is no significant evidence of active inflammation 1

Other Indications (Less Strong)

• Internal fistulas: Surgery is recommended for enterourinary fistulas, fistulas associated with bowel stricture and/or abscess, and fistulas causing diarrhea/malabsorption 1, but these are not considered the primary indication
• External fistulas: Should be managed with a staged approach (fluid/electrolyte balance, sepsis control, nutrition, skin care) before considering surgery 1
• Megacolon syndrome: In toxic megacolon with hemodynamic instability, surgery is indicated but this is a less common presentation 1

Management Algorithm for Intestinal Obstruction in Crohn's Disease

1. Initial presentation with obstruction:

   • If hemodynamically stable without peritonitis: Trial of conservative management with bowel rest, gastric decompression, and IV fluids 1
   • If signs of peritonitis, free perforation, or hemodynamic instability: Immediate surgical exploration 1

2. For persistent or recurrent obstruction:

   • Surgery is the preferred treatment for fibrotic strictures that don't respond to medical therapy 1
   • For short strictures (<5 cm): Consider endoscopic balloon dilatation as an alternative to surgery 1
   • For multiple or long strictures: Surgical intervention is typically required 1

3. Surgical approach:

   • For isolated strictures: Resection or strictureplasty depending on location and length 1
   • For multiple strictures: Combination of resection and strictureplasty to preserve bowel length 1
   • Laparoscopic approach is preferred when appropriate expertise is available 1

Important Considerations

• Strictureplasty is a safe alternative to resection for jejuno-ileal Crohn's disease, with similar short and long-term results 1, 2
• Conventional strictureplasty is advised for strictures <10 cm in length 1
• For extensive disease with long strictured segments, non-conventional strictureplasties may be attempted to preserve bowel length 1
• Strictureplasty is not recommended for colonic strictures due to concerns about cancer risk 1

Caveats and Pitfalls

• Terminal ileitis found incidentally during surgery for suspected appendicitis should not routinely be resected 1
• Appendectomy of a macroscopically normal appendix in the presence of terminal ileitis carries an elevated risk of intra-abdominal septic complications and fistulas 1
• Preoperative optimization with nutritional support and control of sepsis is recommended prior to elective surgery 1
• Patients with multiple previous small bowel resections are at risk for short bowel syndrome, making bowel-preserving techniques like strictureplasty particularly important 2, 3

In conclusion, while all options listed can be indications for surgery in Crohn's disease, intestinal obstruction represents the strongest and most common surgical indication, particularly when it is due to fibrotic strictures that are resistant to medical therapy.