Will a patient with a Crohn's (Crohn's disease) flare and a stricture causing a small bowel obstruction (SBO) require oral prednisone (prednisone) or steroid treatment?

From the Guidelines

A patient with a Crohn's disease flare causing a small bowel obstruction (SBO) due to stricture will likely require systemic corticosteroid treatment, specifically oral prednisone at 40-60mg daily, as recommended by the Canadian Association of Gastroenterology 1. The initial management of such a patient typically includes hospitalization with bowel rest, nasogastric tube decompression, and IV fluids, along with intravenous steroids such as methylprednisolone 40-60mg daily or hydrocortisone 100mg every 8 hours. Once the acute obstruction resolves and the patient can tolerate oral intake, transition to oral prednisone is appropriate, with a gradual taper over 8-12 weeks to minimize steroid-related complications, as suggested by the guidelines for managing luminal Crohn's disease 1. This steroid therapy helps reduce inflammation at the stricture site, potentially allowing the obstruction to resolve without surgery. However, if the obstruction is predominantly fibrotic rather than inflammatory, or if it doesn't respond to medical therapy within 24-72 hours, surgical intervention may be necessary, as indicated by the WSES-AAST guidelines for managing inflammatory bowel disease in the emergency setting 1. Some key points to consider in the management of such patients include:

• The use of oral 5-ASA is not recommended for inducing or maintaining complete remission in patients with Crohn's disease of any severity, as stated in the Canadian Association of Gastroenterology guidelines 1.
• Budesonide may be considered as first-line therapy for mild to moderate ileal and/or right colonic Crohn's disease, but its use for maintaining complete remission is not recommended, as suggested by the guidelines 1.
• Anti-TNF biologics, such as infliximab or adalimumab, may be recommended as first-line therapy for patients with moderate to severe luminal Crohn's disease with risk factors of poor prognosis, or for those who fail to achieve complete remission with other treatments, as recommended by the guidelines 1.
• Endoscopic balloon dilation or stricturotomy may be considered for patients with fibrostenotic disease, but surgery may be necessary for those with intestinal obstruction, long or multiple strictures, or when medical and/or endoscopic treatment fails, as indicated by the WSES-AAST guidelines 1. Additionally, once the acute episode resolves, the patient should be evaluated for maintenance therapy with immunomodulators or biologics to prevent recurrence of stricturing disease and future obstructions, as steroids are not appropriate for long-term management of Crohn's disease, as stated in the guidelines 1.

From the Research

Management of Crohn's Disease with Stricture Causing Small Bowel Obstruction

• The management of stricturing Crohn's disease requires a multidisciplinary and individualized approach, including medical management, therapeutic endoscopy, and surgery 2.
• There is no specific treatment to attenuate scar formation, and current therapies play a limited role in preventing or reversing the process of fibrosis 2, 3.
• Oral prednisone or steroid treatment may not be directly addressed in the provided studies, but the use of anti-tumor necrosis factors (anti-TNFs) such as adalimumab has shown efficacy in patients with Crohn's disease and symptomatic small bowel stricture 4.
• Factors associated with avoiding surgery in patients with small bowel stricture include non-stricturing, non-penetrating disease at onset, mild severity of symptoms, successful endoscopic balloon dilatation (EBD), stricture length < 2 cm, and immunomodulator or anti-TNF added after onset of obstructive symptoms 5.
• The addition of immunomodulator or anti-TNF and smoking cessation may improve the outcome of symptomatic small bowel stricture by avoiding frequent EBD and subsequent surgery after initial EBD 5.

Treatment Options for Intestinal Stricture in Crohn's Disease

• Current therapies for intestinal stricture in Crohn's disease are limited, and nearly half of patients may require surgery 3.
• Endoscopic balloon dilatation (EBD) is a minimally invasive treatment intended to avoid surgery, but its effectiveness in preventing subsequent surgery is unclear 5.
• The use of biologic agents such as adalimumab may be beneficial in patients with Crohn's disease and symptomatic small bowel stricture, with a successful response observed in about two-thirds of patients 4.
• Further research is needed to identify novel drug targets with anti-fibrotic potentiality and to elucidate the pathogenesis of intestinal stricture in Crohn's disease 3.