Management of occlusive Crohn's disease

Background In Crohn's disease occlusion has become the most frequent indication for surgery (30-40%). Methods The authors analyzed the literature of the last two decades by integrating it with their series. Results Patients not responding to conservative therapy, with signs of vascular or impending perforation, should undergo surgery in urgency. An elective surgical procedure is instead possible in cases of persistent obstruction, despite an adequate medical therapy, especially if it is longstanding stenosis with relevant fibrotic component. Preoperatively it is useful a clinical, laboratory and instrumental depth study. CT and MRI allow to rule out concomitant abscesses, to specify localization and extent and to define the degree of disease activity; in the absence of significant signs of nflammation (increased calprotectin, vascularity and contrastenhancement) early surgery is a valid alternative to medical therapy. It is important to evaluate current treatment before the occlusive event in patients destined to early surgery; in fact steroids increase the risk of postoperative complications and therefore they should be scaled. Biologics, also referred to as conservative therapy in patients not intended for immediate surgery, would lead to an increase in postoperative complications (but not infection). The procedure of choice is resection. If there is a concomitant abscess a surgical drainage is required. Stenosis, if endoscopically reachable, can be treated conservatively. Mechanical wide lumen side-to-side anastomosis is the best one, because it has lower complication rates when compared with hand sewing anastomosis. Strictureplasty is reserved for few selected cases with stenosis of the small intestine. Conclusions In Crohn's disease complicated by occlusion, elective surgery should be performed or at least in deferred urgency in order to reduce the incidence of postoperative complications.