Abscess In Crohn Research Articles

Medical Tx an Option for Crohn's Abscesses

Medical Tx an Option for Crohn's Abscesses

The clinical impact of preoperative percutaneous drainage of abdominopelvic abscesses in patients with Crohn’s disease

Although image-guided percutaneous drainage is increasingly being used to treat Crohn's disease-related abdominopelvic abscesses, surgery is seldom avoided. The aim of this study was to compare outcomes following the treatment of intra-abdominal Crohn's abscesses with percutaneous drainage followed by surgery to those after surgery alone. We retrospectively reviewed the charts of patients treated for Crohn's-related abdominopelvic abscesses at Mount Sinai Medical Center between April 2001 and June 2010. Patients who underwent drainage followed by surgery were compared to those who underwent surgery alone. Differences in operative and postoperative outcomes were compared. Seventy patients with Crohn's disease-related abdominopelvic abscesses were identified, 38 (54%) of whom underwent drainage before surgery. Percutaneous drainage was technically successful in 92% of patients and clinically successful in 74% of patients. No differences in rate of septic complications (p = 0.14) or need for stoma creation (p = 0.78) were found. Patients who underwent percutaneous drainage had greater overall hospital lengths of stay (mean 15.8 versus 12.2 days, p = 0.007); 8.6% of patients had long-term postponement of surgery after percutaneous drainage. In our series, the treatment of Crohn's abscesses with percutaneous drainage prior to surgery did not decrease the rate of postoperative septic complications.

The outcome of initial percutaneous drainage versus surgical drainage for intra-abdominal abscesses in Crohn’s disease

Percutaneous drainage (PD) of Crohn's related abscesses is becoming popular with the development of techniques. We retrospectively analyzed the outcome of initial PD versus initial surgical drainage for intra-abdominal abscesses in Crohn's disease. Twenty-three patients of Crohn's disease complicated with intra-abdominal or pelvic abscesses treated in our institution between July 2001 and April 2010 were retrospectively identified from 188 patients with proven Crohn's disease. Outcome measures included abscess recurrence after different treatments, post-drainage complications, ultimate stoma creation, and subsequent surgery for Crohn's disease. Patients were divided into initial PD group (n = 10) and initial surgery group (n = 13): post-drainage complications were more common in initial surgery group (2/10 vs 9/13, P = 0.036), abscess recurred in three patients (2/10 vs 1/13, NS), and subsequent surgery was needed in 10 patients (6/10 vs 4/13, NS). Ultimate stoma creation were significantly more in initial surgery group (1/10 vs 9/13, P = 0.01). Initial PD group had lower rate of post-drainage complications and ultimate stoma creation compared to the initial surgery group. Although subsequent surgery may not be avoided after PD, it can provide safe anastomosis for resections. Long-term follow-up should be done to assess the outcome of PD.

Current Strategies in the Management of Intra-abdominal Abscesses in Crohn's Disease

Crohn's disease is characterized by inflammation that involves the full thickness of the bowel wall, which can lead to serious complications including intra-abdominal and pelvic abscesses. The combination of an intra-abdominal abscess with active Crohn's disease poses a particular dilemma for the treating physician, who must weigh the benefits of using immunosuppressive therapies for the inflammatory bowel disease against the risks of immunosuppression in the presence of serious abdominal infection. Traditionally, Crohn's-related abscesses were managed with early surgery, which often involved external drainage procedures, bowel resection, and the creation of diverting ostomies in acutely ill patients. Today such abscesses often can be managed initially with antibiotics and percutaneous drainage, with evaluation for the need for delayed surgery in selected patients. With delayed surgery performed electively, the surgeon frequently can resect the diseased bowel and create a primary anastomosis, thus avoiding emergency operations and multistage procedures. In highly selected cases, surgery might be avoided entirely. This report reviews the literature on the pathophysiology and management of intra-abdominal abscesses in Crohn's disease (including the roles of percutaneous drainage, immunosuppressive therapy, and surgery), and provides a suggested approach to the management of patients with this difficult problem.

Efficacy of Different Therapeutic Options for Spontaneous Intraabdominal Abscesses in Crohn's Disease

of IBD and pneumologist experts. Clinical data included age, sex, smoking status, disease duration, IBD phenotype according to Montreal classification, concomitant medication and disease activity at the time of diagnosis of bronchopulmonary manifestations. Clinical and morphological description (HRCT), bronchoscopy, bronchoalveolar lavage, histology, and outcome were reviewed. Results: Eighty patients (F 53%, median age 33.5 yrs, UC 47.5%, active smoking 9%) were included. Pulmonary disease was revealed by cough or dyspnoea (90%), frequently after the onset of IBD (85%; median delay after diagnosis was 6 years). At the time of diagnosis of lung disorder, bowel disease was inactive in 41 cases (51%) and lightly to moderately active in 28 cases (35%). Airway disease was present in 53% cases (bronchiectasis: n=25, chronic bronchitis: n=8 and tracheal involvement: n=5) and parenchymal disease in 45% cases (diffuse interstitial lung disease (ILD): n=20,granulomatous lung disease: n=16). Airway disease occurred mainly in UC (n=23/33; 70%) and followed colectomy in 15 cases with a median delay of 4 years (5 months-23 years). Fifty five patients (69%) had steroids with different modalities (inhaled, oral or intravenous). In 89% of cases, improvement or stabilisation were observed (median follow-up of 4 years). Efficacy of immunosuppressants (n=10) was inconsistent and difficult to assess. In granulomatous lung diseases, outcome was constantly favourable, mainly under steroids (n=10). Airway diseases were complicated by infectious diseases in approximately 50% of cases. The prognosis of ILD depended on the parenchymal disease type. Four deaths were reported, 3 of which were secondary to respiratory failure (tracheal involvement: n=1, ILD: n=2). Conclusions: Bronchopulmonary manifestations associated with IBD can be classified in three different types: airway disease, interstitial lung disease and granulomatous disease. Prognosis appears severe in cases of tracheal involvement or interstitial lung disease.

Management of abdominal and pelvic abscess in Crohn's disease.

Patients with Crohn's disease may develop an abdominal or pelvic abscess during the course of their illness. This process results from transmural inflammation and penetration of the bowel wall, which in turn leads to a contained perforation and subsequent abscess formation. Management of patients with Crohn's related intra-abdominal and pelvic abscesses is challenging and requires the expertise of multiple specialties working in concert. Treatment usually consists of percutaneous abscess drainage (PAD) under guidance of computed tomography in addition to antibiotics. PAD allows for drainage of infection and avoidance of a two-stage surgical procedure in most cases. It is unclear if PAD can be considered a definitive treatment without the need for future surgery. The use of immune suppressive agents such as anti-tumor necrosis factor-α in this setting may be hazardous and their appropriate use is controversial. This article discusses the management of spontaneous abdominal and pelvic abscesses in Crohn's disease.

EUS-guided transesophageal, transgastric, and transcolonic drainage of intra-abdominal fluid collections and abscesses

The therapeutic role of EUS is evolving. We report our experience with EUS-guided transesophageal, transgastric, and transcolonic drainage of various intra-abdominal fluid collections. To determine the technical feasibility and clinical outcomes of EUS-guided drainage. Prospective case series. Academic tertiary referral center. Patients referred for endoscopic drainage of intra-abdominal fluid collections; pancreatic pseudocysts amenable to conventional transgastric or transduodenal drainage were excluded. Single-step EUS-guided drainage of fluid collections by using a therapeutic linear-array echoendoscope with fluoroscopic guidance. Technical success, relief of symptoms, and procedural complications. Nine consecutive patients deemed appropriate for EUS-guided drainage of intra-abdominal fluid collections included transesophageal drainage of pseudocysts (n = 2), transgastric drainage of biloma (n = 2) and upper intra-abdominal abscesses (n = 2), transcolonic drainage of diverticular abscess (n = 1), Crohn's abscess (n = 1), and postoperative hematoma (n = 1). Endoscopic drainage was successful in all patients. Confirmation of complete resolution of the target fluid collection and symptom relief was achieved in 8 (89%) of 9 patients. Pneumothorax and mediastinitis developed in 1 patient after transesophageal drainage, which resolved with chest tube and medical therapy. During multiple stent placement, one of the stents was fully deployed into the abscess cavity in 2 patients; both were successfully retrieved either endoscopically (Crohn's abscess) or at the time of primary colonic resection (diverticular abscess). Limited number of patients. EUS-guided transenteric drainage of bilomas, hematomas, abscesses, and inflammatory fluid collections is technically feasible and generally results in complete drainage and symptom relief. Procedural complications may be minimized with more experience.

Sterile Seroma after Surgical Drainage of Purulent Psoas Muscle Abscess in Crohnʼs Disease

Purpose: Introduction: Psoas muscle abscess can occur as a purulent complication of Crohn's Ileitis. We present a case of a sterile seroma of the psoas muscle occurring after surgical drainage of a chronic purulent psoas muscle abscess in Crohn's disease. Case: A 32 years old female underwent Ileal resection for Crohn's Ileitis and drainage of a chronic right psoas muscle abscess. Her psoas muscle abscess had been present for 3 years. She had previously refused surgical resection and drainage of her abscess and was therefore treated with prolonged course of antibiotics. She did not require immunosuppressant, immunomodulators, steroids or biologics postoperatively. 3 years after the resection she presented with right lower quadrant pain and a positive psoas sign. She was afebrile and had a normal white cell count. CT scan showed a 15 cm x 6 cm fluid collection in right psoas muscle at the site of her previous psoas muscle abscess. Colonoscopy with Ileoscopy showed no recurrence of Crohn's disease. Small bowel barium x-ray was negative for ileo-psoas fistula. CT guided aspiration showed a sterile fluid collection, with no organisms and sparse white cells. Multiple cultures were negative. She was treated with a prolonged course of percutaneous drainage and ultimately tetracycline injection to sclerose the remaining sinus tract. There has been no recurrence of her sterile seroma in 3 years. Discussion: Psoas muscle abscess is a known purulent complication of Crohn's ileitis. We describe a sterile seroma of the psoas muscle occurring 3 years after surgical drainage of a chronic purulent psoas muscle abscess. We speculate that the seroma developed in the dead space remaining in the psoas muscle after drainage of the chronic walled off abscess. Her sterile seroma was initially concerning for a recurrent purulent psoas muscle abscess. Gastroenterologists should be aware of the possible development of sterile seromas in such cases.

Perianal anal abscess in Crohn's disease

Perianal anal abscess in Crohn's disease

Percutaneous Drainge and Ileocolectomy for Spontaneous Intraabdominal Abscess in Crohn’s Disease

BackgroundHistorical studies have shown that percutaneous drainage alone for intraabdominal abscess secondary to Crohn’s disease is successful in avoiding surgery in only approximately 50% of patients. Failure, however, can require urgent surgery and is then associated with increased morbidity, extended hospital stays, and increased risk for stoma creation. Because of this, our current protocol is initial percutaneous drainage of the abscess, 5–7 days of broad spectrum IV antibiotics with simultaneous high-dose steroids and hyperalimentation, followed by planned one stage resection with primary anastomosis. The aim of the present study was to evaluate the success of this protocol with regard to length of stay, complications associated with the protocol, and its ability to avoid stoma creation. MethodsA retrospective chart review was performed for all Crohn’s disease patients with intraabdominal abscess who underwent the above protocol from 1992 to the present. ResultsNineteen patients (11 male) were identified. Sixteen underwent ileocolectomy with primary anastomosis while only three patients required an upstream diverting ileostomy in addition to resection due to incompletely drained abscesses. The mean length of hospital stay was 13.9±0.6 days including 6.4±0.4 postoperative days. Four patients had post-op complications that did not require surgery (two self-limited anastomotic bleeds, one wound infection, and one pelvic abscess treated with a percutaneous drain). One patient needed reoperation for a small bowel obstruction. ConclusionsCrohn’s disease patients with intraabdominal abscess can safely undergo planned resection with primary anastomosis if initially treated with successful percutaneous drainage and aggressive antibiotic and steroid management. Such a protocol provides a standard of care against which nonsurgical management can be compared and judged.

Outcome of Surgical Versus Percutaneous Drainage of Abdominal and Pelvic Abscesses in Crohn's Disease

Abdominal and pelvic abscesses are a common complication of Crohn's disease. We studied the effect of the initial choice of therapy on time to resolution of abdominal and pelvic abscesses. We recorded clinical, laboratory, and radiographic data on all adult patients with Crohn's disease and abdominal or pelvic abscesses treated at our institution from 1991 to 2001 and followed > or = 1 yr. Univariate analysis identified variables associated with initial choice of drainage modality. These variables were included in a Cox regression model to identify factors independently associated with time to resolution. Of 66 episodes identified, surgery was the initial modality in 29 and percutaneous drainage in 37. Median time to resolution was not different between surgical drainage (25.0 days, range 0-240) and percutaneous drainage (21.5 days, range 0-182) (p = 0.084). Older age, longer duration of symptoms prior to drainage, no fistula identified radiographically, immune modulator use, no rebound tenderness, and admission to the medical service were factors associated with percutaneous drainage as initial modality. These factors, when incorporated in a Cox regression model, did not significantly affect the time to resolution. Days from onset of symptoms to radiographic diagnosis or drainage were independently associated with time to resolution of the abscess. Time to resolution of abdominal or pelvic abscesses in Crohn's disease is similar with percutaneous drainage and surgery. One-third of patients treated with percutaneous drainage required surgery within 1 yr. Earlier intervention for abdominal and pelvic abscesses is associated with shorter time to resolution.

Transperineal Ultrasound in the Detection of Perianal and Rectovaginal Fistulae in Crohn's Disease

Perianal and rectovaginal fistulae are common complications in Crohn's disease. Magnetic resonance imaging (MRI) and endoanal ultrasound are used for imaging perianal fistulae and abscesses, but both methods require expensive equipment and experienced investigators. Transperineal ultrasound may represent another method of detecting perianal complications in Crohn's disease. We investigated Crohn's disease perianal and rectovaginal fistulae using transperineal ultrasound and compared the findings with results of endoanal ultrasound as reference standard. A total of 46 patients with Crohn's disease and perianal and/or rectovaginal or anovulvar fistulae underwent, transperineal and endoanal ultrasound, on the same day. Transperineal ultrasound was performed using regular convex and high-resolution linear probes. Endoanal ultrasound was performed using an ultrasound system with a 7 MHz rotating endoanal probe. Fistulae were classified according to Parks' classification in intrasphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Rectovaginal or anovulvar fistulae were described separately. Presence of abscesses was also reported. Fifty-two fistulae (3 intra-sphincteric, 28 transsphincteric, 8 suprasphincteric, 2 extrasphincteric, 9 rectovaginal, and 2 anovulvar) were detected by transperineal ultrasound. Endoanal ultrasound confirmed the correct classification of 45 fistulae (predictive positive value: 86.5%). Of the 53 fistulae detected by endoanal ultrasound, 45 were correctly classified by transperineal ultrasound (sensitivity 84.9%). Transperineal ultrasound showed 10 perianal abscesses: 2 horseshoe, 4 deep, and 4 superficial. Endoanal ultrasound confirmed all horseshoe, 3 deep, and 2 superficial abscesses and did not find further abscesses. Transperineal ultrasound is a simple, painless, real-time method to detect and classify perianal and rectovaginal fistulae and/or abscesses in Crohn's disease.

Abscess in Crohn's disease—The knife may not be necessary (An American view)

Abdominal and pelvic abscess complicate the clinical ourse of Crohn’s disease in 10–30% of patients [1]. In some atients it may be the presenting symptom while in others bscess may develop late in the clinical course. The classical pproach to the treatment of an abscess in Crohn’s is surical drainage. However, this is an invasive procedure and f combined with bowel resection, often complicated. Over he past two decades, medical therapy with percutaneous rainage under radiological guidance has become increasngly utilised, either as a temporising measure before surgery allowing optimisation of the general condition of the patient nd ensuring a relatively sterile field of operation). However, here are few large studies formally evaluating the outcome f this approach. The study published by Lee et al. [2] evaluates the outcome f nonsurgical treatment (medical or medical plus percutaeous catheter drainage) in the management of abdominal nd pelvic abscess associated with Crohn’s disease and the actors related to the failure of such an approach. Data from 24 onsecutive patients with abdominal and pelvic abscess were etrospectively analysed. These patients were from a single entre in Korea, a country with a low prevalence of Crohn’s isease [3]. An abscess was defined as an extraluminal fluid ollection with the characteristic radiologic features on CT r US or by aspiration of pus. Barium studies were done o evaluate for fistula. All patients received intravenous 3rd eneration cephalosporine and metronidazole for 4 weeks. t the end of the antibiotic treatment, radiologic evaluation as repeated. After a follow-up period of 47.5 months (range –79), the authors report their approach to be successful in wo-thirds of the cases, with a recurrence rate of only about 6%. Only one patient with recurrence required surgical treatent and other two responded to medical retreatment. Surgial therapy was also required for intractable abscesses (four n medical treatment and one on percutaneous drainage). he authors concluded that nonsurgical treatment should be onsidered as the initial management strategy for Crohn’s isease-related abdominal and pelvic abscess in the absence f relevant fistula and concurrent steroid use. In this regard it

CT-guided percutaneous pelvic abscess drainage in Crohn’s disease

Percutaneous abscess drainage (PAD) is the current therapy for abdominal or pelvic collections. PAD has poorer curative rate for abscesses in Crohn's disease (CD), commonly complicated by wide fistulas and multiloculations. We retrospectively evaluated abscess cure rate, complications and final outcome in 87 CD patients, 70 with spontaneous and 17 with postoperative pelvic abscesses, all treated with CT-guided PAD during the last 7 years. A 77% primary success rate and an 84.3% secondary success rate were obtained without major complications. The higher success rate for PAD was for postoperative (88.2%) rather than spontaneous abscesses (74.2%). Seventy-two percent of treated patients did not develop recurrent abscesses and underwent elective surgery up to 40 months later. PAD in pelvic abscess complicating CD is an effective alternative to early surgery with satisfactory curative success rates. In unsuccessful cases, due to wide fistulas or postoperative anastomotic dehiscence, PAD helped in planning elective surgery, reducing surgical complications.

Psoas abscess in Crohn's disease.

In a series of 161 patients treated surgically for Crohn's disease, 7 patients were seen with a psoas abscess as a complication of the bowel disease. Drainage only was not sufficient to check the rapid downhill course in these patients. Resection of the underlying bowel disease was performed in all patients. There was one death from pulmonary embolism and 3 patients required drainage on more than one occasion.

Mesenteric abscess in Crohn's disease

A 63-year-old man with a 1-year history of ileocolitic Crohn's disease presented with fever (38°C) and left lower quadrant pain of 5 days' duration. On examination, a tender egg-sized round mass was palpable in the left lower abdomen. The white blood cell count was 15.5 × 109/L (normal: 4-9 × 109/L) and C-reactive protein was 18.95 mg/dL (<0.27 mg/dL). CT revealed a mesenteric abscess adjunct to the sigmoid colon (A, arrow). A Gastrografin (Nihon Schering, Osaka, Japan) enema study showed irregular luminal narrowing of the sigmoid colon, suggesting the inflammatory change caused by the extraintestinal lesion (B, arrow).

Contrast radiology, computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohn’s disease: a prospective comparative study

Objectives Accurate assessment of intestinal complications of Crohn’s disease (CD) is extremely important, both in clinical practice and in trials. The accuracy of radiographic and ultrasonographic diagnosis of internal fistulae and abscesses complicating CD is still debated and requires further investigation. We compared ultrasonography (US) and contrast radiography in detecting intestinal fistulae and abscesses complicating CD. Methods A prospective study was carried out on 625 consecutive CD patients who underwent complete evaluation of the intestinal tract by means of colonoscopy and double contrast barium enema, small bowel enteroclysis, and abdominal ultrasound (US). Computed tomography (CT) was also carried out in cases of severe CD with clinical suspicion of septic complications. The accuracy of US, barium radiology, and CT in detecting internal fistulae and abscesses was assessed by comparing results with intraoperative findings in 128 consecutive patients who underwent operation immediately after diagnostic workup. Results Internal fistulae and intra-abdominal abscesses were identified intraoperatively in 56 (43.7%) and 26 (20.3%) patients, respectively. Diagnostic accuracy of US and x-ray studies in detecting internal fistulae was comparable (85.2% vs 84.8%), with sensitivity of 71.4% for US and 69.6% for x-ray studies, and specificity of 95.8% for both. Combination of radiographic techniques and US significantly improved diagnostic accuracy in detection of internal fistulae. In severe cases of CD with clinical suspicion of septic complications such as abdominal mass or fever, the accuracy of US, barium studies, and CT was 88.5%, 80.3%, and 77%, respectively ( p = ns). The presence of abscesses was correctly detected in 90.9% of cases by means of US and in 86.4% by CT ( p = ns), although accuracy was higher for CT (91.8%) than for US (86.9%) because of false positive results in US studies. Conclusion Despite the fact that barium radiology is widely considered the method of choice in detection of internal fistulae, accuracy is not entirely satisfactory. Comparable accuracy was found for US and CT. The combination of barium and US studies, or the sole use of US in more CD patients with more severe disease, can reliably detect most internal fistulae and abscesses.

Crohn’s fistula: current concepts in management

Crohn’s disease was described in 1932 in the classic article by Crohn et al., and then subsequently the authors described one of the disease complications, namely perianal fistula. It was originally thought that the perianal disease originated in the inflamed terminal ileum, which extended internally down to the perianal area. In the last 70 years, we have learned much about this disease, as well as the complications of both perianal and internal fistula. Approximately 60%–70% of all patients with Crohn’s disease will eventually need to undergo surgery, which in many cases is related to the development of a perianal fistula, subsequent to an abscess.1 The purpose of this article is to review our current knowledge of Crohn’s fistula, focusing predominantly on the concepts in clinical management.

Intra-abdominal and pelvic abscess in Crohn's disease: results of noninvasive and surgical management.

Intra-abdominal and pelvic abscesses occur in 10-30 per cent of patients with Crohn's disease. The aim of this study was to establish the clinical characteristics and outcome of patients admitted over a 4-year period with an abdominal or pelvic abscess secondary to Crohn's disease. Patients with Crohn's disease-related intra-abdominal or pelvic abscess were identified from a prospectively collected database, comprising all admissions between 1991 and 1994. Medical records were reviewed retrospectively and data gathered regarding management and outcome. Thirty-six patients were identified with Crohn's disease-related abscess, of whom 15 were considered for initial percutaneous drainage. Drainage was technically possible in eight of these patients: it failed in four, gave good long-term results in two, and was followed by recurrence after 3 years in one and by later surgery unrelated to the abscess in one. Twenty-eight patients underwent surgery, with only four requiring a stoma. Complications occurred in 12 patients. At 3 months, 22 of the 36 patients were in remission. Crohn's intra-abdominal abscesses are associated with a high morbidity rate. Selected cases can be drained percutaneously, without adding to the morbidity, and sometimes resulting in abscess resolution.

Hepatic abscess in Crohn’s disease

Hepatic abscess in Crohn’s disease