A relatively common presentation is for Crohn’s pts with ileitis [surgically naive] to present with a contained microperforation around the T.I. These patients usually respond to antibiotics and a few days of bowel rest. The question is who amongst these needs surgery once the CT scan clears up. Can/should we reintroduce immune suppressing medication [eg anti TNF] to these patients in general? And what if the patient was already on a biologic with an adequate trough [eg adalimumab and trough 13]? Would you consider the presence or absence of a stricture in the T.I. important to decide who needs to go straight to surgery vs those who can try medical therapy first? Thanks !
These situations are common but clinically heterogeneous. If this complication happened in a patient on good maintenance therapy with favourable trough levels, then that therapy has failed and an alternative should be considered. If this happens in a patient shortly after starting medical therapy, it probably means that therapy was introduced too late in the disease course. If this is a first presentation of disease, then we would consider starting biologic therapy once the acute infection has resolved. However our experience is that most of these patients ultimately require surgery. If there is a documented stricture contributing to the penetrating complication then we would bypass medical therapy and go directly to surgery. If not and an abscess recurs upon reintroduction of medical therapy, then we would again advise surgery. In this situation it’s “two strikes and you are out”.