A Clinical and Radiographic Model to Guide Medical versus Surgical Management for Acute Small Bowel Obstruction in Crohnʼs Disease

Abstract

Introduction: Crohn's disease is a chronic inflammatory condition that often leads to stricture formation. For more than half of Crohn's disease patients, the strictures will cause bowel obstructions that require a surgical bowel resection within 10 years of their initial diagnosis. Certain patients may benefit from surgery over prolonged medical management. We evaluated whether CT imaging and clinical criteria obtained at the initial emergency room visit for acute small bowel obstruction are able to predict progression to surgery and readmission. Methods: We performed a retrospective chart review of Crohn's disease patients with acute small bowel obstructions seen in the emergency room. Inclusion criteria included adults (>18 years) admitted with the ICD-10 diagnosis for Crohn's disease and a primary diagnosis of small bowel obstruction. Patients with other causes of small bowel obstructions (e.g. malignancy, adhesions or anastomotic strictures), or without an admission abdominal CT scan with intravenous contrast or a confirmed diagnosis of Crohn's disease were excluded. Two expert abdominal radiologists evaluated the CT scans for bowel wall thickness, maximal and minimal luminal diameters, length of diseased segment, passage of oral contrast, penetrating disease, bowel wall hyperenhancement or stratification, presence of a comb sign, fat hypertrophy, and small bowel feces sign. The primary outcome was progression to surgery (yes/no) and days to readmission. The clinical and radiographic data were analyzed using univariate and multivariable analysis. Results: Forty patients met the inclusion criteria with the majority receiving medical treatment alone (78%) and the minority (22%) underwent surgery. Univariate analysis identified a BMI<25 as a significant predictor for surgery (P=0.04). Multivariable analysis of BMI and radiographic features consisting of involved segment length, penetrating disease, and bowel wall hyperenhancement produced a model that predicted progression to surgery with an AUC of 91% (95%CI 0.80-1.01), 78% sensitivity, and 84% specificity. Kaplan-Meier curves of high-vs. low-risk patients revealed significant separation for the time to readmission (P=0.04). Conclusion: We describe a model based on clinical and radiographic data collected in an emergency room setting that predicts progression to surgery and readmission. The model has the potential to stratify patients, guide management in the acute setting, and assess future risk for readmission.613_A Figure 1 No Caption available.613_B Figure 2 No Caption available.