Initial Management Orders for Crohn's Disease Flare with Small Bowel Obstruction
Immediate Resuscitation and Stabilization
All patients with Crohn's flare and small bowel obstruction require aggressive intravenous fluid resuscitation, electrolyte correction, and thromboprophylaxis as the foundation of initial management. 1
IV Fluids and Electrolytes
- Order aggressive IV crystalloid resuscitation (typically 1-2 liters bolus followed by maintenance at 125-200 mL/hr) to correct dehydration and electrolyte abnormalities 1, 2
- Check and correct electrolyte abnormalities including sodium, potassium, chloride, bicarbonate, magnesium, and phosphate 1, 2
- Assess and correct anemia with CBC; transfuse if hemoglobin <7 g/dL or symptomatic 1
Thromboprophylaxis
- Order low-molecular-weight heparin (e.g., enoxaparin 40 mg subcutaneous daily) for thromboprophylaxis due to increased thrombotic risk in IBD patients 1
NPO and Bowel Decompression
- Make patient NPO (nothing by mouth) 2
- Place nasogastric tube if significant abdominal distension or vomiting to decompress the bowel and remove proximal contents 3, 2
Laboratory Orders
Initial Labs
- Complete blood count with differential - assess for leukocytosis, bandemia, anemia 2
- Comprehensive metabolic panel - evaluate electrolytes, renal function, liver function 2
- Lactate level - elevated lactate suggests bowel ischemia or strangulation 2
- C-reactive protein and erythrocyte sedimentation rate - assess inflammatory activity 4
- Albumin and prealbumin - evaluate nutritional status 4
- Vitamin B12, folate, vitamin D levels - assess nutritional deficiencies 4
- Type and screen - prepare for potential transfusion or surgery 1
Critical warning signs requiring immediate surgical consultation include marked leukocytosis with bandemia and lactic acidosis, which suggest advanced obstruction with ischemia. 2
Imaging Orders
Primary Imaging
Order CT abdomen and pelvis with IV contrast immediately - this is the preferred initial imaging modality with >90% diagnostic accuracy for detecting obstruction, identifying the cause, and evaluating for complications such as ischemia 5
Do NOT order oral contrast in high-grade obstruction - this delays diagnosis, increases patient discomfort, and risks aspiration 5
Key CT Findings to Assess
The radiologist should specifically evaluate for:
- Signs of ischemia/strangulation: abnormal bowel wall enhancement, intramural hyperdensity, bowel wall thickening, mesenteric edema, ascites, pneumatosis 5
- Pneumoperitoneum and free fluid - indicates perforation requiring immediate surgery 6, 5
- Abscess presence and size - abscesses >3 cm require percutaneous drainage 1
- Stricture characteristics - length, location, degree of obstruction 5
Medical Management Orders
Anti-inflammatory Therapy
Order IV corticosteroids (e.g., methylprednisolone 40-60 mg IV daily or hydrocortisone 100 mg IV every 8 hours) as initial medical treatment for severe active Crohn's disease in hemodynamically stable patients 1
Assess response to IV steroids by day 3 - if no improvement, consider rescue therapy with infliximab or surgical consultation 1
Antibiotic Considerations
Order IV antibiotics ONLY if there is evidence of:
- Abscess (small <3 cm abscesses can be treated with antibiotics alone; >3 cm require percutaneous drainage) 1
- Superinfection 1
- Signs of sepsis or perforation 1
Antibiotic regimen should cover: Gram-negative aerobic/facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli (e.g., piperacillin-tazobactam 3.375 g IV every 6 hours or ceftriaxone 1-2 g IV daily plus metronidazole 500 mg IV every 8 hours) 1
Do NOT routinely administer antibiotics without evidence of infection - this is a common pitfall 1
Nutritional Support Orders
Order total parenteral nutrition (TPN) for nutritionally deficient patients who cannot tolerate enteral nutrition, including those with high-output fistula, severe intestinal hemorrhage, or those requiring emergency surgery 1
Consultation Orders
Immediate Surgical Consultation Required If:
- Signs of strangulation, perforation, or ischemia on imaging 6, 5
- Pneumoperitoneum with free fluid on CT 6, 5
- Hemodynamic instability with persistent obstruction 5
- Complete obstruction failing medical therapy after 3-5 days 6, 5
Gastroenterology Consultation
Order GI consultation for all Crohn's patients with SBO to guide medical management and determine if stricture is inflammatory (may respond to medical therapy) versus fibrotic (requires intervention) 5
Monitoring Orders
- Continuous telemetry if hemodynamically unstable
- Vital signs every 4 hours (or more frequently if unstable)
- Strict intake and output monitoring
- Daily weights
- Serial abdominal exams - worsening peritoneal signs indicate need for surgery 2
Critical Decision Points
Surgery is mandatory for: 6, 5
- Symptomatic fibrotic strictures not responding to medical therapy and not amenable to endoscopic dilatation
- Free perforation with peritonitis
- Persistent hemodynamic instability despite resuscitation
- Complete obstruction failing 3-5 days of medical therapy
- Signs of bowel ischemia or strangulation
Common pitfall to avoid: Delaying surgery in critically ill patients with signs of ischemia, strangulation, or perforation significantly increases mortality from 10% to 30% 5, 2
Another critical pitfall: Failing to distinguish inflammatory versus fibrotic strictures - inflammatory strictures may respond to corticosteroids and biologics, while fibrotic strictures require surgical or endoscopic intervention 5