What is the best approach to manage stomach contractions in a patient with Crohn's disease and a history of gastrointestinal issues, potentially on anti-TNF therapy?

Management of Stomach Contractions in Crohn's Disease

For a patient with Crohn's disease experiencing stomach contractions (likely representing obstructive symptoms from stricturing disease or active inflammation), the primary approach is conservative management with bowel rest, gastric decompression, intravenous fluids, and intravenous corticosteroids if active inflammation is present, while avoiding emergency surgery unless there are signs of perforation or peritonitis. 1

Initial Assessment and Conservative Management

Deferred surgery is the preferred option for acute small-bowel obstruction without bowel ischemia or peritonitis. 1 The management algorithm should proceed as follows:

• Implement bowel rest, nasogastric decompression, and intravenous fluid resuscitation as first-line conservative measures for obstructive symptoms 1
• Administer intravenous corticosteroids if active inflammatory disease is present to address the underlying inflammation contributing to symptoms 1
• Obtain early surgical consultation to jointly monitor progress and assess for surgical indication, even while pursuing conservative management 1

Role of Anti-TNF Therapy

Anti-TNF therapy should only be initiated after any abscesses have been treated with antibiotics and drainage (strong recommendation) 1. This is a critical safety consideration that must not be overlooked.

For patients already on anti-TNF therapy who develop obstructive symptoms:

• Continue anti-TNF therapy if the patient has achieved symptomatic response, as discontinuation increases relapse risk 1, 2
• Ensure therapeutic drug levels are maintained, as subtherapeutic levels may contribute to inadequate disease control 2
• Consider switching to alternative biologics (vedolizumab, ustekinumab, or risankizumab) if there is documented loss of response to anti-TNF therapy despite adequate drug levels 3, 4

Definitive Management Based on Stricture Characteristics

For short strictures (<5 cm) of the terminal ileum, both endoscopic balloon dilation and surgery are suitable options, with choice depending on local expertise and patient preference 1. However:

• Preoperative optimization is essential: nutritional status, immunosuppression control, and sepsis management must be addressed before elective surgery 1
• Emergency resection should be avoided unless there is intestinal perforation, as immediate surgery in the acute setting leads to worse outcomes 1

Critical Pitfalls to Avoid

• Never start anti-TNF therapy in the presence of untreated intra-abdominal abscess - this can lead to septic complications in up to one-third of patients 1
• Do not proceed directly to emergency surgery for obstructive symptoms without attempting conservative management first, unless perforation or peritonitis is present 1
• Avoid corticosteroids for maintenance therapy - they are appropriate for acute symptom control but should not be used long-term (strong recommendation) 1, 3

Monitoring and Escalation

• Clinical and radiological monitoring should guide the decision to continue conservative management versus proceed to surgery 1
• Recurrent episodes of subacute obstruction warrant surgical consultation and discussion of definitive treatment options, as these tend to recur over time 1
• Multidisciplinary team involvement is essential for complex cases, particularly those with multiple complications 1