What is the best treatment approach for severe abdominal pain in Crohn’s disease?

Treatment of Severe Abdominal Pain in Crohn's Disease

For severe abdominal pain in Crohn's disease, intravenous corticosteroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are the first-line treatment, with infliximab considered for patients who fail to respond to steroids, particularly in cases of penetrating ileocecal disease. 1

Initial Assessment and Management

• All patients with severe abdominal pain due to Crohn's disease should receive a multidisciplinary approach involving both a gastroenterologist and an acute care surgeon to determine the optimal treatment strategy 1
• Patients should receive adequate intravenous fluids, low-molecular-weight heparin for thromboprophylaxis, and correction of electrolyte abnormalities and anemia 1
• Vital signs should be monitored frequently, with laboratory tests (CBC, ESR/CRP, electrolytes, albumin, liver function) checked every 24-48 hours 1

First-Line Medical Treatment

• Intravenous corticosteroids are the primary treatment for severe abdominal pain in active Crohn's disease:

  • Hydrocortisone 400 mg/day or methylprednisolone 60 mg/day 1
  • Response to IV steroids should be assessed by the third day of treatment 1
  • If oral therapy is possible, prednisolone 40 mg daily is appropriate for moderate to severe disease 1

• For isolated ileo-cecal disease with moderate activity, budesonide 9 mg daily may be used as it has fewer systemic side effects, though it is marginally less effective than prednisolone 1

Management of Non-Responders

• If no improvement occurs within 48-72 hours of initiating IV corticosteroids, consider second-line therapy 1
• Infliximab should be considered if anti-inflammatory therapy is required for penetrating ileocecal Crohn's disease, following adequate resolution of any intra-abdominal abscesses 1, 2
• For non-responder hemodynamically stable patients, medical rescue therapy including infliximab in combination with a thiopurine should be considered 1

Management of Complications

• If abdominal pain is associated with intra-abdominal abscesses:

  • Small abscesses (<3 cm) can be treated with intravenous antibiotics 1
  • Larger abscesses (>3 cm) should be managed with percutaneous drainage plus antimicrobial treatment 1
  • Surgery should be considered if percutaneous drainage fails or if the patient has signs of septic shock 1

• Antibiotics should not be routinely administered unless there is evidence of superinfection or intra-abdominal abscess 1

  • When needed, antimicrobial therapy should target gram-negative aerobic and facultative bacilli, gram-positive streptococci, and obligate anaerobic bacilli 1
  • Concomitant intravenous metronidazole is often advisable when distinguishing between active disease and septic complications is difficult 1

Nutritional Support

• Nutritional support is mandatory in severely undernourished patients 1

• Total parenteral nutrition should be reserved for:

  • Nutritionally deficient patients unable to tolerate enteral nutrition 1
  • Cases where the enteral route is contraindicated 1
  • Critically ill patients with signs of shock, intestinal ischemia, high output fistula, or severe intestinal hemorrhage 1
  • When emergency surgery is needed for complicated IBD 1

• Elemental or polymeric diets may be used to induce remission in selected patients with active Crohn's disease who have contraindications to corticosteroid therapy 1

Biological Agents

• Infliximab (5 mg/kg at weeks 0,2, and 6, then every 8 weeks) is effective for moderate to severe Crohn's disease that has failed conventional therapy 2
• Adalimumab can be used as an alternative biological agent, particularly for maintenance therapy 3
• For complex perianal fistulizing disease, infliximab or adalimumab can be used as first-line therapy in combination with azathioprine following adequate surgical drainage 1

Considerations for Surgical Management

• If a patient's condition deteriorates despite medical therapy, surgical consultation should be obtained 1
• Surgery should be considered for patients with enteric fistulae and persistent sepsis despite initial treatment 1
• Preoperative treatments with immunomodulators, anti-TNF agents, and steroids are risk factors for intra-abdominal sepsis in patients requiring emergency surgery 1

Cautions and Monitoring

• Patients on corticosteroids should be monitored for side effects including Cushing syndrome, acne, infection, hypertension, diabetes, osteoporosis, and cataracts 1
• When using biologics like infliximab, monitor for serious infections including tuberculosis, bacterial sepsis, and invasive fungal infections 2
• Perform TB testing before starting anti-TNF therapy and monitor for active TB during treatment 2