Outcome of surgical and medical treatment of abscess

in Crohn’s disease

Prof Dr Nasir Khokhar MD FACP FACF

Professor and Chief of Gastroenterology

Shifa International Hospital,

Islamabad

Pathogenesis

Spontaneous or post operative 10-30% patients develop spontaneous

abscesses in their lifetime Occur due to transmural inflammation and

micro perforation of diseased bowel Most common locations: abd wall, rectus

sheath, ileo paoas muscle, gluteal

Yamaguchi A, Matsui T, Sakurai T, Ueki T, Nakabayashi S, Yao T,. The clinical characteristics outcome

of intraabdominal abscess in Crohn’s disease. J Gastroenterol 2004;39:441-8

Pathogenesis of abscess

Clinical presentation and diagnosis• History, physical examination and imaging:

Elderly and immunosuppressed may not show symptoms

• Spiral CT • CT enterography; may demonstrate fistula and

extent and degree of bowel wall inflammation:

Inflammatory mass: phlegmon. Well defined border: abscess

• Aspiration of pus

Gutierrez A, Lee H, Sands BE. Outcome of surgical versus percutaneous drainage of

abdominal and pelvic abscesses in Crohn’s disease. Am J Gastroenterol 2006; 101: 2283-2289

Rectal Abscess

Thick walled pelvic abscess

Intra abdominal abscess

CT guided PAD• Clinical status: No peritonitis and

hemodynamically stable: Appropriate antibiotics• PAD initial choice: Advantages; Delayed surg

until sepsis controlled, nutrition improved and steroids tapered

• Drain as much pus; Size <3 cm only antibiotics ok

• Approaches: Transgluteal, transabdominal, perineal, transrectal, transvaginal

• EUS or laparoscopic approach

Poritz LS, Koltun WA. Percutaneous drainage and ileoco- lectomy for spontaneous intraabdominal abscess in

Crohn’s disease. J Gastrointest Surg 2007; 11: 204-208

Outcome of PAD• Success: Resolution of symptoms, collapse of

abscess cavity and avoidance of early surgery (30-60 days)

• Success rate 50-95%• Poor outcome: Multiple or multilocular

abscesses, Associated fistula, spontaneous vs postoperative (77% vs 83%)

• In failure, a sinogram will show fistlua and will need surgery

Golfieri R, Cappelli A. Computed tomography-guided per-cutaneous abscess drainage in coloproctology: review of

the literature. Tech Coloproctol 2007; 11: 197-208

Timing of surgery after PAD

• Controversial: Do all need surg after PAD? Residual bowel disease: only 23% avoided surgery after 7 year FU

• Success in 84% after 7 days: Many wait 6-8 weeks

• Nutritional status important for surgery

• Risk of dehiscence, if patient on steroids for >3 months

Cellini C, Safar B, Fleshman J. Surgical management of pyogenic complications of Crohn’s disease. Inflamm Bowel

Dis 2010; 16: 512-517

Outcome of surgery and PAD

Summary• Spontaneous abscess in 10-30% patients

with Crohn’s disease in their lifetime

• PAD is first choice: Surgery afterwards

• Multiple abscesses and fistulae need surgery

• Malnutrition and steroids lead to poor outcome

• Highly skilled team of gastroenterologists, surgeons and interventional radiologists is required

Famous people with Crohns

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