From the Guidelines
Patients with Crohn's disease should be admitted to the hospital if they have a Crohn's Disease Activity Index (CDAI) score of 220 or higher, or if they exhibit severe symptoms that cannot be managed as an outpatient, including severe abdominal pain, significant dehydration, high fever, persistent vomiting, evidence of bowel obstruction, significant gastrointestinal bleeding, or severe perianal disease, as indicated by the AGA clinical practice guidelines 1.
Criteria for Admission
The following criteria should be considered for hospital admission:
- Severe symptoms, such as severe abdominal pain, significant dehydration, high fever, persistent vomiting, evidence of bowel obstruction, significant gastrointestinal bleeding, or severe perianal disease
- CDAI score of 220 or higher
- Presence of complications, such as abscess formation, fistulas, strictures causing obstruction, or toxic megacolon
- Acute flares unresponsive to outpatient therapy
- Concerning laboratory abnormalities, such as severe anemia (hemoglobin <10 g/dL), elevated inflammatory markers (CRP >50 mg/L), or electrolyte disturbances
Management of Crohn's Disease in the Hospital
Once admitted, treatment typically includes:
- Bowel rest
- IV fluids for rehydration
- IV corticosteroids (methylprednisolone 40-60 mg daily or hydrocortisone 100 mg every 8 hours)
- Pain management
- Antibiotics if infection is suspected
- Biologics like infliximab (5 mg/kg IV) may be initiated for severe cases not responding to steroids
- Surgical consultation should be obtained for patients with suspected complications requiring potential surgical intervention, as recommended by the WSES-AAST guidelines 1.
Key Considerations
- The optimal management of IBD patients presenting with acute abdominal pain is multidisciplinary, involving a gastroenterologist and an acute care surgeon 1.
- All IBD patients presenting with an acute abdomen should receive adequate volume of intravenous fluids, low-molecular-weight heparin for thromboprophylaxis, and electrolyte abnormalities and anemia should be corrected 1.
- Antibiotics should not be routinely administered, but only if superinfection is considered and in the presence of an intra-abdominal abscess 1.
From the Research
Criteria to Admit Crohn's to Medicine
The following criteria can be considered to admit Crohn's disease patients to medicine:
- Active Crohn's disease with a Crohn's disease activity index (CDAI) of 220 or higher 2
- Inadequate response to conventional therapy, such as corticosteroids and immunomodulators 3, 4
- Presence of fistulizing Crohn's disease, with a goal of reducing the number of draining fistulas 3
- Need for maintenance therapy to sustain clinical remission and prevent complications 2, 4
- Patient risk stratification, including factors such as age of onset, disease severity, and presence of penetrating complications 4
Treatment Options
Treatment options for Crohn's disease patients admitted to medicine may include:
- Infliximab, an anti-tumor necrosis factor-alpha (anti-TNFα) therapy, which has been shown to be effective in inducing and maintaining remission 3, 2, 5
- Adalimumab, another anti-TNFα therapy, which has been shown to have similar response characteristics to infliximab 5
- Concomitant immunomodulator therapy, such as azathioprine or 6-mercaptopurine, which may be used in combination with infliximab to achieve optimal maintenance of response 3, 5
- Corticosteroids, which may be used for rapid palliation of symptoms during initiation of anti-TNFα therapy 4
- Monoclonal antibodies to IL-12/23 or integrin α4β7, which may be used as alternative therapies 4
Safety Considerations
Safety considerations for Crohn's disease patients admitted to medicine may include: