Treating Bowel Obstruction in Crohn's Disease

In part 2 of this roundtable of APPs specializing in the care of patients with IBD, the participants review the diagnosis of intestinal obstruction in a patient with Crohn's disease and the steps to take to treat the condition, in addition to working with a patient with anxiety about IBD therapies.

Kimberly Kearns, MS, ANP-BC, specializes in adult gastroenterology for DULY Health and Care in Hoffman Estates, Illinois. Kimberly Orleck, PA-C, is a nurse practitioner at Atlanta Gastroenterology Associates Associates and director of Advanced Practice Providers at United Digestive in Atlanta, Georgia. Abigail Meyers, MPAS, PA-C, is assistant director of student success and development and an assistant professor at the Medical College of Wisconsin in Milwaukee, Wisconsin. Angelina Collins, MSN, ANP-BC, is a specialist in inflammatory bowel disease at the University of California San Diego Inflammatory Bowel Disease Center.

TRANSCRIPT:

Angelina Collins:

Well, generally when you have an inflamed segment like this or you have a retained capsule, I mean certainly before we do something invasive, we usually like to give a course of prednisone to see if that will quiet down the inflammation and enough and allow a capsule to then move through this particular area. So that's typically what we do. Our practice is usually to start prednisone 40 milligrams a day, do that for 14 days, and then start tapering by 5 milligrams a week until completed.

Here you have a little bit, this is a little different scenario, right, because part of the reason you're giving the prednisone, and I suppose we didn't even ask if she's symptomatic of this retained capsule, and that's probably an important feature as well. But with something like this, I mean there's a stricture here that's limiting the capsule from going through. So she may well be symptomatic, but still prednisone would be a reasonable thing to do unless she's obstructedly symptomatic and then she really needs to go into the hospital for IV solumedrol. Then discussion with surgical management, et cetera.

Abigail Meyers:

I concur. I would be looking for those signs of observation, inability to pass gas or significant bloating distension, particularly in that right lower quadrant, based upon having this retained capsule. And I think we've all kind of been there in these situations. We're like, dang it, I didn't want that to happen. And when we have our IBD hats on versus our anemia hats, we can get a different picture there. So that would be the first things I would check for the opposite patient or kind of the obstructive symptoms. And then we would do the same thing that Angelina does, give some steroids to help reduce that inflammation or even consider maybe if the endoscopy previously didn't go, depending upon how far they intubated into the terminal ileum, we may be able to look to see if we can send them to an advanced endoscopy team a little bit deeper innovation. Again, if there's a significant degree of inflammation there that may not be in the patient's safest, best interest, but if there is an opportunity to visualize that capsule and remove it endoscopically, that's something we could consider, too.

Kimberly Kearns:

Alright, so here's our scenario. This young woman has a significant history of anxiety and depression, as we've already talked about, fortunately or unfortunately has no symptoms of obstruction. None at all, right? Beyond the fact that she presented with abdominal bloating, which I think in retrospect she was symptomatic from her stricture, right? And I think that that was kind of a learning point as well, even for the GI partner that was managing this patient as well. So with that, agreed 100% this patient was started on high-dose steroids as an outpatient. Technically, do you know if someone does not have signs or symptoms of obstruction, can we leave a capsule in place?

The answer is yes. I know Angelina's shaking her head, the answer's yes. I mean, you don't have to mad dash this patient to a surgeon if they're not obstructed. And technically there is data that looks at what we call capsule retention or leaving capsules in place. And technically a retention is actually anything greater than 8 weeks, just so that we know that's the technical definition of that. But as long as the patient is not showing signs of obstruction, can it actually not need to be urgently removed? The answer is yes, but as Angelina would say, and I'm sure Abby would also say X marks the spot, we know that there's a problem there. We know the diameter of a capsule. If we put out our index finger, we know that the capsule is no bigger than our index finger. We have to recognize that that stricture is pretty predominant.

So with that in mind, we put her on steroids. She's not showing any signs of symptoms of obstruction. We re-x-ray her. The capsule's still there. Now what are you going to do? Now she's a bionaive patient. She's 24 years old again, I do want to let you know this case all happened in 2020, by the way. So let's put our hats on. We're going to talk about 2020 and then we can talk about 2024 if you'd like. But if this was, and Angelina, I know we don't always get these bionaive patients, but we already know what's happening. What would you actually do next in this scenario?

Angelina Collins:

Yeah, well, I mean there's a lot. The nice thing is you have a lot of options. And so the great news is that just to highlight, she's not symptomatic. The bloating—I think the good point about bloating is usually postprandial bloating in my mind is a sign is the milder sign of obstruction. So that postprandial notation of when bloating's occurring, I think, or if you get distension with that, I think that that's a good sign as well of there being obstructive or structuring-type symptoms going on here. So I think because this is a naive patient, but it sounds like despite— and I don't know how long the course of prednisone was, but you're giving a reasonable course, high dose course of prednisone at this point and nothing's really getting any better. So what do you want to do? Again, still patient's not obstructing. So you again, still don't have to send the patient to surgery. Although in some situations, like what's your preference? 2020 was the time, I don't know about your guys' locations, but people were not going into the hospital unless they had COVID. And so it was very difficult to access a lot of things. So at that time in particular, I had a couple of patients who were supposed to be having planned resections who were just on the edge and they had to be postponed several times because of COVID, because what was happening because of COVID. And so elective surgeries weren't happening for us at that time. And so they had be emergent. And so this patient would not have qualified in this situation, not having symptoms would not be considered with an emergent need for surgery. So she would not have been able to go in and have surgery even if that would've been her preference because now I think there'd be this conversation depending on, we didn't talk about how long the segment is, but would that be a primary course, is to think about a resection first instead of going to therapy?

And we can talk about that. That's going to get complicated. But I think medication, you have to treat the inflammation. You can see that this is an inflammatory stricture. So where there is inflammation, there is hope that medication will work. So getting on effective therapy right away, I probably would favor something. I think there's multiple right answers to this. So showing your math is probably important. I would just say, so I think there's multiple right answers here. I want something that's going to work fast. I want to dose, I really want to dose optimize here. I probably would pick combination therapy with infliximab plus an immunomodulator, to be honest. And I would be early checking dose concentrations during induction probably at week 6 to see if I'm going to get to the right level and really try to treat this down quickly and go from there. That would probably be my preference if she will buy the lemonade that I'm selling.

Kimberly Kearns:

Excellent. Abby, bionaive, 24, tell me how you'd manage this. And by the way, she was actually on 4 weeks of higher dose steroids in my opinion, and believe it or not, we started on 50 milligram to really try to really try and see if we could pass this capsule, pass the capsule through wasn't on 50 for 4 weeks, forgive me, she was on 50 and then over 4 weeks had a taper. So we'll keep that in mind. Again, capsule did not move at all with her subsequent imaging. So Abby, now giving you some additional information. It's like clue, putting together all the pieces here, right?

Abigail Meyers:

Well, as you mentioned, 8 weeks is kind of our marker, our endpoint marker. So we're halfway there. And I would like to kind of echo what Angelina was saying, and I look at it in the way of the risk stratification. When we look at Crohn's disease—she's under 30, she's got a stricture and she doesn't have extensive disease that we know of. I mean, we don't know how long the segment is, but we know that her future looks like it could be a more of this moderate/severe kind of more aggressive type picture. So I would favor probably an anti-TNF therapy. I like the idea of more dose adjustability. So I would tend to lean a little bit more towards the infliximab realm in that regard. And I would be a little bit more proactive with my drug monitoring.

Given her anxiety around all of these things—and I'm sure we're going to get into the discussion of how she feels about these potential side effects—I would love to add an immune modulator to help to improve those infliximab outcomes. But if there is an issue with her receptive nature about this, then I would favor just at least if we could just get infliximab. The other thing I consider with her is that if she believes that she was not terribly symptomatic to begin with, this is what I call a hard sell. And so she might be a little bit more resistant to her diagnosis, particularly in 2020, where you're going to be put on medications that suppress your immune system, you're going to have more frequent visits. She already has maybe some as she has this anxiety kind of baseline. So I think this is going to require a lot of handholding, a lot of education, and a lot of helping her to understand what Crohn's disease means, and not just what it means today, but what it means for the progression.

And usually when you can get some buy-in from that, which is built upon mutual respect and shared decision making and a lot of empathetic communication skills, when we can get the buy-in, then there's this realization that comes 4, 6 months later that's like, oh my gosh, I actually felt horrible and I didn't know that. And so we know that because we see these people, but helping them to become a little bit more introspective and realize that maybe things were a little bit worse than they thought. So that's where I would probably start next is a little bit more aggressive medical management based upon that higher risk stratification.

Kimberly Kearns:

Totally agree with both of you, and I want to let you know, and again, the reason I keep pointing out the anxiety component to this is that this young woman, you're right, did not have the buy-in and again, wasn't feeling so terrible. And so when we talked to her about Crohn's disease, it was really, really hard to actually have the discussion with her. So I actually printed out all of her pictures, which I do for all of my patients, and had to show her. I'm like, this is actually what the inside of your swelling intestine looks like. So again, we talk about what the outside doesn't always reflect on what's happening on the inside. So showed her the images, so on and so forth. And again, her anxiety levels and especially considering it was 2020 talking about, again, TNF was definitely discussed with an immunomodulator. And I can tell you that that was completely 100%, as I'm sure you can guess, shot down, she was not moving forward.

This, and this is where I always tell, and I think we started some of this discussing the shared decision making. I always tell a patient, this is your IBD journey. We are here as providers to help guide you along on that journey. And we're going to help with guidance to the best of our abilities. But ultimately, and this is what we have to say, is our patients get to make their own decisions. So if they're not buying the lemonade, as Angelina likes to say, we can make sure we get everything set up, but if they're not going to proceed with therapy, I don't think that that creates that therapeutic relationship that we're looking for. So with that, we really had to come and have a discussion because this was all about recognizing she needed advanced therapy, 100% this patient needed advanced therapy, but where in that paradigm did she feel comfortable with that advanced therapy?

And I will tell you that where she landed with vedolizumab, so she landed with vedolizumab and was started on vedolizumab. And with that, I will tell you in about 24 months, and I'm sorry, not 24 months, I apologize, I have it down here, 24 weeks, she ended up in the hospital with a partial small bowel obstruction in a community-based hospital. So with that being said, I'm sure you guys can imagine what we did next was we put her on IV steroids to kind of help and see, and that capsule—we named her Claire—the capsule was still present after that 24 week mark. And with that then was referred to some of our tertiary care partners as well. And ultimately this patient ended up, and again, which we're not really going to dive today's discussion, but ultimately ended up with a resection. And again, that sometimes is part of our treatment plan, right, is needing a resection.