Emergency Management of Crohn's Disease Flare-up

Initial Assessment and Stabilization

All IBD patients presenting with acute abdominal pain should receive adequate volume of intravenous fluids and correction of electrolyte abnormalities and anemia 1
Low-molecular-weight heparin should be administered for thromboprophylaxis due to the increased risk of thrombotic events in IBD patients 2
IV contrast-enhanced CT scan is recommended to exclude intestinal perforation, stenosis, bleeding, and abscesses, which helps guide decision-making for immediate surgery or initial conservative management 3
Point-of-care ultrasonography can be useful when CT is unavailable to assess for free intra-abdominal fluid, intestinal distension, or abscesses 4

Intravenous corticosteroids are the initial medical treatment for severe active disease in hemodynamically stable patients 1
Response to intravenous steroids should be assessed by the third day 1
In non-responders who remain hemodynamically stable, rescue therapy including infliximab in combination with a thiopurine, or ciclosporin should be considered 1
Small abscesses (<3 cm) should be treated with intravenous antibiotics with close clinical and biochemical monitoring 5
For abscesses >3 cm, radiological percutaneous drainage combined with antimicrobial therapy is recommended as first-line treatment 2
Antibiotics should target Gram-negative aerobic and facultative bacilli, Gram-positive streptococci, and obligate anaerobic bacilli according to local epidemiology and resistance patterns 1
Surgery should be considered if percutaneous drainage fails or if the patient shows signs of septic shock 2

In stable patients with GI bleeding, CT angiography is recommended to localize the bleeding site before potential angio-embolization or surgery 3
Initial evaluation with sigmoidoscopy and esophagogastroduodenoscopy is suggested for hemodynamically stable patients 6
Immediate surgery is recommended for unstable patients with hemorrhagic shock who don't respond to resuscitation 7

Surgery is mandatory for symptomatic intestinal strictures that don't respond to medical therapy and aren't amenable to endoscopic dilatation 6
Any colorectal stricture should be assessed with endoscopic biopsies to rule out malignancy 6

Total parenteral nutrition is recommended for nutritionally deficient IBD patients who cannot tolerate enteral nutrition or when the enteral route is contraindicated 2
This includes patients with high-output fistula, severe intestinal hemorrhage, or those requiring emergency surgery 2

Infliximab should be considered for penetrating ileocecal Crohn's disease requiring anti-inflammatory therapy, following adequate resolution of intra-abdominal abscesses 2
For complex perianal fistulizing disease, infliximab or adalimumab can be used as first-line therapy in combination with azathioprine following adequate surgical drainage 2

Antibiotics should not be routinely administered unless there is evidence of superinfection or intra-abdominal abscess 1
Preoperative treatments with immunomodulators associated with anti-TNF-α agents and steroids increase the risk of intra-abdominal sepsis in patients requiring emergency surgery 2
Patients with enteric fistulae may require surgical intervention if clinical evidence of sepsis persists despite initial treatment 2