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, typically intravenous steroids initially rather than oral prednisone. The standard approach involves hospitalization with bowel rest (NPO status), intravenous fluids, nasogastric tube decompression if needed, and IV methylprednisolone 40-60mg daily or equivalent, as suggested by the Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease 1. This initial management aims to reduce inflammation and potentially resolve the obstruction without surgery. If the patient improves, they can transition to oral prednisone (typically 40mg daily with a gradual taper over 8-12 weeks) before discharge, as recommended for patients with moderate to severe Crohn's disease who have failed to respond to oral budesonide or have active Crohn's disease of sufficient severity to require hospitalization 1. However, if the obstruction doesn't resolve with medical management within 24-72 hours, surgical intervention may be necessary to address the stricture, as suggested by the WSES-AAST guidelines for the management of inflammatory bowel disease in the emergency setting 1. Some key points to consider in the management of Crohn's disease flares with SBO due to stricture include:

• The use of systemic corticosteroids to reduce inflammation and potentially resolve the obstruction
• The importance of hospitalization and bowel rest in the initial management
• The potential need for surgical intervention if medical management fails
• The use of endoscopic balloon dilation or surgical resection for persistent strictures once the acute inflammation subsides, as discussed in the WSES-AAST guidelines 1. It's also important to note that while steroids may help resolve the acute obstruction, they don't treat the underlying stricture, and many patients will ultimately require further intervention. The WSES-AAST guidelines suggest that patients with small bowel stenosis mainly due to inflammation may improve with medical treatment such as steroids, but those with fibrotic strictures may require endoscopic dilation or surgical intervention 1. Overall, the management of Crohn's disease flares with SBO due to stricture requires a multidisciplinary approach and careful consideration of the underlying cause of the obstruction.

From the Research

Treatment Options for Crohn's Stricture with SBO

• The treatment of Crohn's stricture with small bowel obstruction (SBO) depends on various factors, including the clinical presentation, nature of the stricture, and anatomical characteristics 2.
• Medical therapy, mainly biologics, surgical resection, and endoscopic interventions are available therapeutic options for managing symptomatic Crohn's stricture 2, 3.
• However, there is no direct evidence to suggest that oral prednisone or steroid treatment is required for a patient with a Crohn's flare and a stricture causing an SBO.

Management of Stricturing Crohn's Disease

• Stricturing of the gastrointestinal tract is a common complication in Crohn's disease, and its management requires a multidisciplinary and individualized approach 3.
• The treatment options for stricturing Crohn's disease include medical management, therapeutic endoscopy, and surgery 3, 4.
• Adalimumab, an anti-tumor necrosis factor (TNF) agent, has been shown to be effective in patients with Crohn's disease and symptomatic small bowel stricture, with a success rate of 64% at week 24 5.

Factors Associated with Surgery in Patients with Small Bowel Stricture

• 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 6.
• 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 6.