A 28-year-old man with Crohn's disease (ileocolonic) on azathioprine monotherapy for 2 years presents with a 4-week history of progressive abdominal pain, non-bloody diarrhea (5–6 stools/day), and weight loss (3 kg). Examination reveals a palpable mass in the right lower abdomen. CT enterography shows a 4 cm segment of ileac stricture with proximal bowel dilatation, no fistulae, and no free perforation. CRP is 5.2 mg/dL (mildly elevated). What is the most appropriate next step in management?

Explanation

## Clinical Presentation Analysis **Crohn's disease with symptomatic stricture:** - Ileocolonic location (typical site) - Fibrostenosing phenotype (stricture with proximal dilatation) - Mild-to-moderate inflammation (CRP 5.2, non-bloody diarrhea) - No fistulae or perforation - Inadequate control on azathioprine monotherapy ## Stricture Management Algorithm ```mermaid flowchart TD A[Crohn's stricture confirmed]:::outcome --> B{Fulminant obstruction?}:::decision B -->|Yes: vomiting, severe pain, no flatus| C[Emergency surgery]:::urgent B -->|No: partial obstruction, tolerable symptoms| D{Inflammatory or fibrotic?}:::decision D -->|Inflammatory component| E[Optimize medical therapy]:::action E --> F[TNF inhibitor + immunomodulator]:::action F --> G[Nutritional support: enteral nutrition]:::action G --> H[Reassess at 6-8 weeks]:::decision H -->|Improved| I[Continue medical therapy]:::action H -->|Worsening or no response| J[Consider endoscopic dilation or surgery]:::action D -->|Purely fibrotic, no inflammation| K[Surgical resection]:::action ``` ## Why Enteral Nutrition + TNF Inhibitor Is Correct **Key Point:** Symptomatic strictures with **inflammatory component** (elevated CRP, mild-moderate symptoms) should receive **optimized medical therapy** before surgery. TNF inhibitors are superior to conventional steroids for stricturing Crohn's disease. **High-Yield:** Management of fibrostenosing Crohn's: 1. **Enteral nutrition** (polymeric or elemental): - Anti-inflammatory effect - Promotes mucosal healing - Reduces need for surgery - Preferred over TPN (lower infection risk) 2. **TNF inhibitor** (infliximab or adalimumab): - More effective than steroids for stricturing disease - Combined with azathioprine for synergy - Allows steroid sparing 3. **Reassess at 6–8 weeks** for symptom improvement and imaging response **Clinical Pearl:** Strictures in Crohn's are often **mixed** (inflammatory + fibrotic). Early TNF inhibitor use can prevent progression to purely fibrotic disease requiring surgery. **Mnemonic:** **FIST** = Fibrostenosing Crohn's needs **I**nfliximab + **S**upplemental **T**ubes (enteral nutrition). ## Why Surgery Is Not First-Line Here - No fulminant obstruction (patient tolerating oral diet) - Inflammatory component present (CRP elevated) - Stricture is partial, not complete - Medical therapy not yet optimized (azathioprine monotherapy is inadequate) [cite:Harrison 21e Ch 298]