What is the best approach to manage pain associated with cobblestoning in a patient with Crohn's disease?

Management of Pain Associated with Cobblestoning in Crohn's Disease

For pain associated with cobblestoning (a manifestation of active mucosal inflammation in Crohn's disease), initiate intravenous corticosteroids as first-line therapy if the pain is severe, or oral budesonide 9 mg daily for isolated ileocecal disease with moderate activity. 1

Initial Assessment and Severity Stratification

Determine whether the cobblestoning represents active inflammatory disease requiring immediate treatment versus complications such as strictures, abscesses, or fistulae that may need surgical intervention. 1

• Monitor vital signs frequently (at minimum four times daily) and obtain laboratory markers including complete blood count, C-reactive protein or ESR, electrolytes, albumin, and liver function tests every 24-48 hours to assess disease severity 1
• Obtain plain abdominal radiography to exclude colonic dilatation (transverse colon diameter >5.5 cm) or other complications 2
• Ensure multidisciplinary involvement with both gastroenterology and acute care surgery to determine optimal treatment strategy 1

First-Line Medical Management for Severe Pain

Administer intravenous corticosteroids as the primary treatment for severe abdominal pain due to active Crohn's disease, using either hydrocortisone 400 mg/day or methylprednisolone 60 mg/day. 1

• Provide adequate intravenous fluids, correct electrolyte abnormalities and anemia, and administer low-molecular-weight heparin for thromboprophylaxis 1
• Assess response to IV steroids by the third day of treatment 1
• If no improvement occurs within 48-72 hours of initiating IV corticosteroids, escalate to second-line therapy such as infliximab 1

Management for Moderate Disease Activity

For isolated ileocecal disease with moderate activity, use budesonide 9 mg daily as it has fewer systemic side effects, though it is marginally less effective than prednisolone. 1

• Oral prednisolone 40 mg daily remains an alternative for patients who fail topical therapy or have more extensive disease 2
• Reduce prednisolone gradually according to severity and patient response, generally over 8 weeks 2

Evaluation for Complications

Rule out intra-abdominal abscesses, as these require specific management before escalating immunosuppression. 1

• Small abscesses (<3 cm) can be treated with intravenous antibiotics alone 1
• Larger abscesses (>3 cm) require percutaneous drainage plus antimicrobial treatment targeting gram-negative aerobic and facultative bacilli, gram-positive streptococci, and obligate anaerobic bacilli 1
• Consider infliximab only after adequate resolution of any intra-abdominal abscesses if anti-inflammatory therapy is required for penetrating ileocecal Crohn's disease 1

Management of Perianal Disease and Fistulae

If cobblestoning is associated with perianal disease or fistulae, initiate metronidazole 400 mg three times daily and/or ciprofloxacin 500 mg twice daily as first-line treatment for simple perianal fistulae. 2

• Consider azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day for simple perianal or enterocutaneous fistulae where distal obstruction and abscess have been excluded 2
• Reserve infliximab (three infusions of 5 mg/kg at 0,2, and 6 weeks) for patients whose fistulae are refractory to other treatment, using it as part of a strategy that includes immunomodulation and surgery 2

Nutritional Support

Provide nutritional support in severely undernourished patients, reserving total parenteral nutrition for those unable to tolerate enteral nutrition. 1

• Elemental or polymeric diets may be used to induce remission in selected patients with active Crohn's disease who have contraindications to corticosteroid therapy 1

Surgical Consultation

Obtain surgical consultation if the patient's condition deteriorates despite medical therapy, or if there are signs of septic shock, failed percutaneous drainage, or persistent sepsis with enteric fistulae. 1

• Surgery should be considered for patients with enteric fistulae and persistent sepsis despite initial treatment 1
• Be aware that preoperative treatments with immunomodulators, anti-TNF agents, and steroids are risk factors for intra-abdominal sepsis in patients requiring emergency surgery 1

Monitoring and Follow-Up

Monitor patients on corticosteroids for side effects including Cushing syndrome, acne, infection, hypertension, diabetes, osteoporosis, and cataracts. 1

• Recognize that inflammation often persists in the absence of gastrointestinal symptoms and may lead to progressive bowel damage 3
• Use objective markers of inflammation (fecal calprotectin, CRP) rather than relying solely on symptomatic assessment 2

Common Pitfalls

• Do not delay corticosteroid treatment while awaiting stool microbiology results in acute presentations 2
• Do not routinely administer antibiotics unless there is evidence of superinfection or intra-abdominal abscess 1
• Do not initiate infliximab before adequately draining intra-abdominal abscesses, as this increases risk of septic complications 1
• Avoid relying solely on symptom assessment, as up to 20-50% of patients with Crohn's in remission still experience pain despite controlled inflammation 4