Conservative management of spontaneous intra‐abdominal abscess in Crohn's disease: Outcome and prognostic factors

Abstract

Objective To compare the outcomes of different treatments for spontaneous intra‐abdominal abscesses (IAA) in active Crohn's disease (CD). Methods A retrospective analysis of patients with CD between January 2007 and December 2018 was performed in two Belgian inflammatory bowel disease centers. Successful conservative management was defined as complete resolution of abscesses without the need for bowel resection. The primary outcome was suboptimal evolution, defined as a composite outcome of recurrence of abscess, postoperative complications or the need for a non‐elective resection. Results Forty CD patients presenting with 43 independent episodes of spontaneous IAA development were included. One underwent immediate bowel resection. In all other 42 cases a conservative approach was taken, which led to a complete abscess resolution rate of 28.6% (12/42). The remaining abscesses required bowel resection. Anti‐tumor necrosis factor (TNF) agent use was associated with successful conservative management (odds ratio [OR] 13.36, 95% confidence interval [CI] 11.19‐15.52, P = 0.006), while the opposite trend was found for corticosteroids (OR 0.14, 95% CI 0.02‐1.26, P = 0.055). There was a trend towards suboptimal evolution in case of previous bowel resection (OR 4.77, 95% CI 0.77‐29.66, P = 0.094) or in patients aged above 50 years (OR 5.17, 95% CI 0.86‐30.91, P = 0.072). Conclusions Bowel resection appears to be inevitable in most CD patients presenting with IAA. An attempt at conservative treatment may be particularly successful with anti‐TNF agents in younger patients who have not undergone previous bowel resection. Large‐scale prospective studies are needed to confirm these findings.

Microbial Spectrum and Antibiotic Resistance in Patients Suffering from Penetrating Crohn’s Disease

“…International guidelines recommend intravenous antibiotic therapy and therapeutic (percutaneous) drainage if abscess formation exceeds 3 cm in diameter [ 6 , 9 , 10 , 11 ]. So far, empiric antibiotic therapy included a combination of metronidazole with fluoroquinolones or third generation cephalosporins [ 6 , 18 ], but these recommendations are mainly based on case series and retrospective monocentric data, respectively [ 15 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ]. In line with that, a recently published multicentric prospective European study evaluating the microbial spectrum of intra-abdominal abscess formation in patients suffering from Crohn´s disease demonstrated a high rate of inadequate antimicrobial empirical first-line therapy [ 16 ].…”

High complication rate in Crohn’s disease surgery following percutaneous drainage of intra-abdominal abscess: a multicentre study

“…Percutaneous drainage can prevent the need for surgery in up to 30% of selected CD patients with the use of anti-tumor necrosis factor agents being associated with the higher success of conservative management [ 13 ], once sepsis had resolved [ 14 ], but our study cannot provide guidance on the outcomes of patient who did not require surgery following drainage, as these have not been captured. A recent multicentre study including 335 CD patients with percutaneous drainage followed by surgery [ 15 ] reported a complication rate of 32.2%, with residual abscess, low serum albumin concentration [ 16 ], and an interval of less than 2 weeks between drainage and surgery, being associated with higher risk of complications.…”

Intra‐abdominal abscesses in CD – When to treat with biologics?

“…The majority (71.4%) of patients required bowel resection to achieve complete abscess resolution. The risk factors for the failure of conservative treatment were the use of corticosteroids and the non‐use of anti‐TNF agents after abscess diagnosis 17 . However, clear criteria leading to surgical indication are still not known.…”

“…The risk factors for the failure of conservative treatment were the use of corticosteroids and the non‐use of anti‐TNF agents after abscess diagnosis. 17 However, clear criteria leading to surgical indication are still not known. History of medical treatment refractory disease, presence of a symptomatic stenosis and/or enterocutaneous fistula are arguments in favor of surgical management.…”