A 45-year-old man with a 15-year history of Crohn’s disease presents to the emergency department with severe abdominal pain, nausea, and vomiting. He reports that the pain started suddenly and has been worsening over the past 24 hours. On examination, he has significant abdominal distension and tenderness, particularly in the mid-abdomen. Bowel sounds are high-pitched and hyperactive. An abdominal X-ray reveals dilated loops of small bowel with multiple air-fluid levels.
Given the clinical scenario described, what is the most likely indication for surgical intervention in this patient with Crohn’s disease?
A. Perianal disease
B. Intestinal fistula
C. Small bowel obstruction
D. Crohn’s colitis
Correct Answer: C. Small bowel obstruction
Explanation:
Small bowel obstruction:
Small bowel obstruction is the most frequent indication for surgery in patients with Crohn’s disease. This condition often results from strictures caused by chronic inflammation, fibrosis, and scarring of the intestinal wall. In the scenario described, the patient’s symptoms of severe abdominal pain, nausea, vomiting, abdominal distension, hyperactive bowel sounds, and radiographic evidence of dilated bowel loops with air-fluid levels are characteristic of a small bowel obstruction. Surgical intervention is typically required to relieve the obstruction and prevent complications such as bowel perforation or ischemia.
Explanation of Incorrect Options:
A. Perianal disease:
Perianal disease, including abscesses and fistulas, is a common manifestation of Crohn’s disease but less frequently requires emergency surgery compared to small bowel obstruction. Management often involves medical therapy and minor surgical procedures like drainage.
B. Intestinal fistula:
Intestinal fistulas are a complication of Crohn’s disease and can lead to chronic issues, but they are less likely to present as an acute emergency compared to small bowel obstruction. Surgery for fistulas is generally elective and planned based on the patient’s overall condition.
D. Crohn’s colitis:
Crohn’s colitis involves inflammation of the colon and may lead to symptoms such as diarrhea and abdominal pain. However, it is less likely to necessitate urgent surgical intervention compared to small bowel obstruction. Surgery for Crohn’s colitis is usually considered for complications like strictures, fistulas, or failure of medical therapy.
Given these considerations, small bowel obstruction (Option C) is the most likely indication for surgical intervention in the scenario described.