What are the drugs of choice for managing suspected Crohn's disease in a patient with intestinal perforation?

Management of Suspected Crohn's Disease with Intestinal Perforation

For a 27-year-old male with intestinal perforation and suspected Crohn's disease, immediate surgical intervention followed by appropriate medical therapy is the recommended management approach.

Acute Management of Intestinal Perforation

Surgical Management

• Free perforation with peritonitis is an absolute indication for emergency surgery in Crohn's disease 1
• Resection of the perforated segment with or without anastomosis is the operation of choice 1
• In hemodynamically unstable patients, an open surgical approach is recommended 1
• In hemodynamically stable patients, a laparoscopic approach may be considered if expertise is available 1
• For perforated ileum with peritonitis, resection, lavage, and stoma formation is suggested to avoid complications associated with anastomotic leak 1
• If there is only localized contamination and the patient is hemodynamically stable, primary anastomosis may be considered 1

Perioperative Antimicrobial Therapy

• Broad-spectrum antibiotics should be initiated immediately 1
• For critically ill or immunocompromised patients with adequate source control:
  • Piperacillin/tazobactam 6 g/0.75 g loading dose then 4 g/0.5 g q6h or 16 g/2 g by continuous infusion 1
  • In patients with beta-lactam allergy: Eravacycline 1 mg/kg q12h 1
• Antibiotic therapy should be continued for up to 7 days based on clinical conditions and inflammatory markers 1

Post-Surgical Medical Management for Crohn's Disease

Initial Medical Therapy

• After control of sepsis and confirmation of Crohn's diagnosis, anti-TNF therapy should be considered as first-line treatment 1, 2
• Infliximab is recommended if anti-inflammatory therapy for penetrating ileocecal Crohn's disease is required, following adequate resolution of intra-abdominal abscesses 1
• Standard induction regimen for infliximab: 5 mg/kg at weeks 0,2, and 6, followed by maintenance therapy every 8 weeks 2
• Clinical trials have shown that infliximab maintenance therapy (5 mg/kg every 8 weeks) leads to significantly higher rates of clinical remission compared to placebo 2

Important Considerations for Medical Therapy

• Weaning off steroids (ideally 4 weeks preoperatively) and stopping immunomodulators associated with anti-TNF agents before surgery is recommended to decrease postoperative complications 1
• Prednisolone 20 mg daily or equivalent for more than 6 weeks is a risk factor for surgical complications 1
• Anti-TNF therapy is associated with higher postoperative septic complications after abdominal surgery for Crohn's disease 1
• Nutritional support (parenteral or enteral, according to GI function) should be administered as soon as possible 1

Long-term Management and Monitoring

Disease Monitoring

• A multimodal approach to monitoring remission is advised, including clinical, biochemical, imaging, and endoscopic modalities 1
• Fecal calprotectin should be used to monitor disease activity 1
• Cross-sectional imaging (MRI or CT) and intestinal ultrasound may be used to evaluate both luminal and extraluminal disease 1

Maintenance Therapy Considerations

• Withdrawal of purine analogues or anti-TNF therapy is associated with a significant risk of relapse 1
• Patients who achieve a response with infliximab and subsequently lose response may benefit from dose escalation (5 mg/kg higher than the previous dose) 2
• At Week 54 of treatment with infliximab maintenance therapy, 38% of patients had no draining fistulas compared with 22% of placebo-treated patients 2

Common Pitfalls and Caveats

• Free perforation in Crohn's disease is relatively rare, occurring in approximately 1-3% of patients, but requires immediate surgical intervention 3
• Perforating disease phenotype may have a more aggressive course with higher recurrence rates compared to non-perforating disease 4
• Patients with Crohn's disease who undergo emergency operations typically have a severe form of disease, are often malnourished, and may be on medications that increase surgical risk 1
• Early involvement of a multidisciplinary team consisting of an IBD gastroenterologist, an IBD surgeon, a radiologist, and a dietitian is mandatory in emergency presentation of Crohn's disease 1
• Preoperative optimization of an emergency Crohn's disease patient and transfer of care from the acute to the specialized/elective setting is key to improving short- and long-term postoperative outcomes 1