What is the management for a female patient with a history of Crohn's disease (CD) presenting with right iliac fossa pain and fever?

Management of Crohn's Disease with Right Iliac Fossa Pain and Fever

For a female patient with Crohn's disease presenting with right iliac fossa pain and fever, intravenous antibiotics should be initiated promptly, followed by consideration of steroids if inflammatory markers are elevated, while azathioprine should be avoided during the acute phase due to potential complications. 1

Initial Assessment and Management

• Right iliac fossa pain with fever in a Crohn's disease patient requires urgent evaluation for potential complications such as abscess formation, intestinal obstruction, or perforation 1
• Perform laboratory tests including complete blood count, C-reactive protein, liver and renal function tests to assess disease activity and guide treatment decisions 1
• Radiological assessment with CT enterography or MRI is essential to identify potential complications such as abscesses, strictures, or perforation 1

Antibiotic Therapy

• Empiric antibiotic therapy should be initiated promptly in patients presenting with fever and right iliac fossa pain to control potential sepsis 1
• For small abscesses (<3 cm), intravenous antibiotics alone may be sufficient, though there is risk of recurrence, especially if associated with enteric fistula 1
• For larger abscesses (>3 cm), percutaneous drainage combined with antibiotics is recommended as a bridging procedure before considering surgery 1

Steroid Therapy

• In the presence of active inflammatory disease without abscess, intravenous steroids should be considered to control inflammation 1
• Steroids are highly effective for inducing remission in acute flares but should be used cautiously if infection is not adequately controlled 2
• Intravenous steroids are particularly indicated when there are signs of intestinal obstruction due to inflammatory stenosis without evidence of perforation or peritonitis 1

Azathioprine Considerations

• Azathioprine should NOT be initiated during an acute flare with fever as it may increase the risk of serious infections and complications 3
• The FDA label for azathioprine warns that patients receiving immunosuppressants are at increased risk for bacterial, viral, fungal, and opportunistic infections 3
• Azathioprine is more appropriate for maintenance therapy after remission has been achieved rather than for treating acute flares 1, 4

Surgical Considerations

• Surgery should be considered in the following scenarios:
  • Failure of percutaneous drainage of abscesses 1
  • Persistent signs of sepsis despite medical management 1
  • Evidence of intestinal perforation, massive bleeding, or clinical deterioration 1
  • Intestinal obstruction due to fibrotic or medically-resistant stenosis 1

Management Algorithm

1. Immediate management:

   • Start intravenous antibiotics for fever and suspected infection 1
   • Perform imaging (CT enterography or MRI) to assess for complications 1

2. If abscess is detected:

   • For abscess <3 cm: Continue antibiotics with close monitoring 1
   • For abscess >3 cm: Perform percutaneous drainage plus antibiotics 1

3. If no abscess but active inflammation:

   • Initiate intravenous steroids to control inflammation 1
   • Monitor response within 24-48 hours 1

4. If intestinal obstruction:

   • Conservative management with bowel rest, gastric decompression, and IV fluids if no signs of peritonitis 1
   • Consider surgery if obstruction persists or worsens 1

5. Maintenance therapy (only after acute phase resolves):

   • Consider azathioprine or other immunomodulators for maintenance 1
   • Biologic agents may be needed for moderate to severe disease 1

Important Caveats

• Azathioprine carries significant risks including bone marrow suppression, serious infections, and increased risk of lymphoma, particularly hepatosplenic T-cell lymphoma in young patients 3
• Always rule out infectious causes that may mimic Crohn's disease flares, as inappropriate immunosuppression in the setting of infection can worsen outcomes 5
• Patients on immunosuppressive therapy require close monitoring for adverse effects including cytopenias and opportunistic infections 3