Abdominal Abscess in Crohn's Disease: Multidisciplinary Management

Abstract

Crohn's disease (CD) is characterized by full-thickness inflammation of the bowel. For this reason, perforating complications such as intra-abdominal abscesses or fistulas are common. A concomitant intra-abdominal abscess with active CD of the small bowel is a challenging dilemma for gastroenterologists and surgeons. Since there is active and severe disease, this should be treated with immunosuppressive drugs. However, in the presence of an intra-abdominal abscess, immunosuppression can be dangerous. There are several treatment options for intra-abdominal abscesses in CD. Nowadays, the first-line treatment is antibiotic therapy with or without percutaneous drainage. Historically, patients were treated with surgical drainage. With the development of percutaneous drainage, treatment shifted to a more nonsurgical approach. Success rates for percutaneous drainage in the literature vary from 74 to 100%, and it is considered to be a relatively safe procedure. It has been reported that surgery can be avoided after successful percutaneous drainage in a variable number of patients (14-85%). If sepsis is controlled, CD medication should be started to prevent recurrence. It is important to monitor the effect upon CD lesions to avoid further perforating complications. Finally, an undrainable or small abscess can be treated with antibiotics alone, although high recurrence rates have been described with this approach. Patients with a concomitant stenosis, an enterocutaneous fistula or refractory active disease are likely to require surgery. Percutaneous drainage in combination with delayed surgery is useful to improve the patient's condition prior to surgery and is associated with less morbidity, a lower stoma rate and more limited resection. In conclusion, when feasible, percutaneous drainage and antibiotics should be the treatment of choice in patients with an intra-abdominal abscess in CD. If surgery is inevitable, this must be delayed to reduce postoperative septic complications and high stoma rates.

Large retroperitoneal abscess extended to the inferior right limb secondary to a perforated ileal Crohn's disease: the importance of the multidisciplinary approach

“…Concerning the surgical approach the present case did not meet the criteria for a safe laparoscopic procedure (9-15), due to its large diffusion in the soft tissues and the enteric quality of the collection. In the present case our approach appears in line with the indications of the literature (4,5,9,16). The bowel was resected removing the diseased segment of terminal small bowel and ileo-cecal junction as indicated in the most part of experiences (5,9,11,12).…”

“…The full thickness inflammation of the intestinal wall develops in strictures, fistulas and abdominal abscesses (1)(2)(3)(4). These are the most common complications during the course of the illness (5) and surgical treatment is frequently required in these occurrences.…”

“…Nowadays in case of a well-circumscribed intra-abdominal abscess the most accepted therapeutic option is antibiotic therapy and, in case of need, percutaneous drainage of the abscess (4,6). The perforation can result in a retroperitoneal abscess that can reach the psoas and iliac spaces (7).…”

“…After the previous surgical drainage, the persisting septic collections were treated with a CT-guided non-surgical drainage. It can be the definitive treatment that could solve the abscess in two third of the cases (4,11,(25)(26)(27).…”

Indian Society of Gastroenterology consensus statements on Crohn’s disease in India

“…Importantly, following abscess resolution, 60 % of patients could be started on thiopurines and 9 % on biologics, while in 31 %, baseline therapy was not modified. While percutaneous drainage is increasingly used, by itself or as a bridge to surgery, as treatment of intraabdominal abscesses in CD [90], in one study, it was found that only one third of abscesses treated with percutaneous drainage showed long-term resolution compared to 90 % of those undergoing immediate surgical drainage [91]. In a meta-analysis of CD patients in remission, neither sulfasalazine nor mesalamine were effective in preventing relapse in patients with quiescent CD, but in a per protocol analysis, mesalamine appeared to reduce risk of relapse (RR=0.79; 95 % CI=0.66-0.95, NNT=13) [68].…”