What is the treatment for a Crohn's disease flare-up in the Emergency Room (ER)?

Emergency Management of Crohn's Disease Flare-up

The treatment of a Crohn's disease flare-up in the emergency room requires a multidisciplinary approach involving gastroenterologists and acute care surgeons, with initial management focusing on intravenous fluids, electrolyte correction, and appropriate medical therapy based on disease severity and complications. 1

Initial Assessment and Stabilization

• All IBD patients presenting with acute abdominal pain should receive adequate volume of intravenous fluids and correction of electrolyte abnormalities and anemia 1
• Low-molecular-weight heparin should be administered for thromboprophylaxis due to the increased risk of thrombotic events in IBD patients 1
• IV contrast-enhanced CT scan is recommended to exclude intestinal perforation, stenosis, bleeding, and abscesses, which helps guide decision-making for immediate surgery or initial conservative management 1
• Point-of-care ultrasonography can be useful when CT is unavailable to assess for free intra-abdominal fluid, intestinal distension, or abscesses 1

Medical Management Based on Complications

Uncomplicated Flare-up

• Intravenous corticosteroids are the initial medical treatment for severe active disease in hemodynamically stable patients 1
• Response to intravenous steroids should be assessed by the third day 1
• In non-responders who remain hemodynamically stable, rescue therapy including infliximab in combination with a thiopurine, or ciclosporin should be considered 1

Abscess Management

• Small abscesses (<3 cm) should be treated with intravenous antibiotics with close clinical and biochemical monitoring 1
• For abscesses >3 cm, radiological percutaneous drainage combined with antimicrobial therapy is recommended as first-line treatment 1
• Antibiotics should target Gram-negative aerobic and facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli according to local epidemiology and resistance patterns 1
• Surgery should be considered if percutaneous drainage fails or if the patient shows signs of septic shock 1

Gastrointestinal Bleeding

• In stable patients with GI bleeding, CT angiography is recommended to localize the bleeding site before potential angio-embolization or surgery 1
• Initial evaluation with sigmoidoscopy and esophagogastroduodenoscopy is suggested for hemodynamically stable patients 1
• Immediate surgery is recommended for unstable patients with hemorrhagic shock who don't respond to resuscitation 1

Intestinal Obstruction

• Surgery is mandatory for symptomatic intestinal strictures that don't respond to medical therapy and aren't amenable to endoscopic dilatation 1
• Any colorectal stricture should be assessed with endoscopic biopsies to rule out malignancy 1

Nutritional Support

• Total parenteral nutrition is recommended for nutritionally deficient IBD patients who cannot tolerate enteral nutrition or when the enteral route is contraindicated 1
• This includes patients with high-output fistula, severe intestinal hemorrhage, or those requiring emergency surgery 1

Biologic Therapy Considerations

• Infliximab should be considered for penetrating ileocecal Crohn's disease requiring anti-inflammatory therapy, following adequate resolution of intra-abdominal abscesses 1
• For complex perianal fistulizing disease, infliximab or adalimumab can be used as first-line therapy in combination with azathioprine following adequate surgical drainage 1
• Caution must be exercised with biologics as patients treated with TNF blockers are at increased risk for developing serious infections that may lead to hospitalization or death 2, 3

Common Pitfalls and Caveats

• Antibiotics should not be routinely administered unless there is evidence of superinfection or intra-abdominal abscess 1
• Preoperative treatments with immunomodulators associated with anti-TNF-α agents and steroids increase the risk of intra-abdominal sepsis in patients requiring emergency surgery 1
• Patients with enteric fistulae may require surgical intervention if clinical evidence of sepsis persists despite initial treatment 1
• Patients should be closely monitored for the development of signs and symptoms of infection during treatment with biologics, including the possible development of tuberculosis 2