From the Guidelines
A short course of intravenous steroids is the most appropriate initial treatment for suspected Crohn's disease with phlegmon and partial obstruction, as it can help reduce inflammation and improve symptoms. I recommend methylprednisolone 40-60mg IV daily for 3-5 days, as suggested by the Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease 1. This approach is supported by the guideline's conditional recommendation for the use of intravenous corticosteroids, such as methylprednisolone, to induce symptomatic remission in patients with active Crohn's disease of sufficient severity to require hospitalization.
Key Considerations
- During the acute phase, it is essential to maintain bowel rest with nothing by mouth (NPO) status, provide IV fluids for hydration, and initiate nasogastric tube decompression if significant distention is present.
- Antibiotics such as ciprofloxacin 400mg IV twice daily and metronidazole 500mg IV three times daily should be added if infection is suspected, although the Canadian Association of Gastroenterology guideline suggests against the use of systemically absorbed antibiotics to induce or maintain complete remission in patients with Crohn's disease of any severity 1.
- Gastroenterology and surgical consultation are essential for management and to determine if endoscopic or surgical intervention may be needed, as outlined in the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1.
Monitoring and Follow-up
- Close monitoring is required as steroids may mask signs of perforation or worsening infection, and patients should be evaluated for symptomatic response to intravenous methylprednisolone within 1 week to determine the need to modify therapy, as recommended by the Canadian Association of Gastroenterology guideline 1.
- After the initial course of IV steroids, oral prednisone 40mg daily can be started, with a gradual taper over 8-12 weeks, to maintain remission and minimize the risk of relapse.
From the Research
Management of Suspected Crohn's Disease with Phlegmon and Partial Obstruction
- The use of intravenous (IV) steroids in the management of suspected Crohn's disease with phlegmon and partial obstruction is a common practice, as it helps to reduce inflammation and induce remission 2, 3.
- A short course of IV steroids can be effective in rapidly palliating symptoms and improving the patient's condition, allowing for the initiation of other treatments such as anti-tumor necrosis factor α therapy 2.
- However, the use of IV steroids should be carefully considered, as it may be associated with adverse reactions such as osteoporosis, infections, and toxicity to the bone marrow and liver 2, 3.
- In patients with phlegmon, antibiotics should be used in conjunction with IV steroids to control infection, and anti-tumor necrosis factor (TNF) antibody therapy may be considered as an alternative to surgical resection after infection has been controlled 4.
- The treatment approach should be individualized based on disease severity, patient risk stratification, and clinical factors, and should include a comprehensive management plan to prevent complications and improve patient outcomes 2, 5, 3.
Treatment Options
- Corticosteroids, such as IV steroids, are commonly used to treat symptom flare-ups in patients with Crohn's disease 2, 3.
- Biologics, such as anti-TNF antibody therapy, may be used in patients with higher-risk disease to induce and maintain remission 2, 4.
- Immunomodulators, such as azathioprine/mercaptopurine, may be used in combination with biologics to maintain remission 6.
- Surgical interventions, such as resection or strictureplasty, may be necessary in some cases to manage complications such as partial obstruction or phlegmon 6, 4.
Patient Care
- Patients with Crohn's disease should be counseled on smoking avoidance or cessation, as smoking can exacerbate the disease and increase the risk of complications 3.
- Patients should also be screened for osteoporosis, anemia, nutritional deficiencies, depression, infection, and thrombotic events, and preventive measures should be taken to minimize these risks 3.