Current strategies in the management of intra-abdominal abscesses in Crohn's disease

Second Korean guidelines for the management of Crohn's disease

Crohn's disease (CD) is a chronic, progressive, and disabling inflammatory bowel disease (IBD) with an uncertain etiopathogenesis. CD can involve any site of the gastrointestinal tract from the mouth to the anus, and is associated with serious complications, such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower compared with those in Western countries, but they have been rapidly increasing during the recent decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies have been applied for the treatment of this disease. Concerning CD management, there have been substantial discrepancies among clinicians according to their personal experience and preference. To suggest recommendable approaches to the diverse problems of CD and to minimize the variations in treatment among physicians, guidelines for the management of CD were first published in 2012 by the IBD Study Group of the Korean Association for the Study of Intestinal Diseases. These are the revised guidelines based on updated evidence, accumulated since 2012. These guidelines were developed by using mainly adaptation methods, and encompass induction and maintenance treatment of CD, treatment based on disease location, treatment of CD complications, including stricture and fistula, surgical treatment, and prevention of postoperative recurrence. These are the second Korean guidelines for the management of CD and will be continuously revised as new evidence is collected.

Factors associated with surgery in patients with intra-abdominal fistulizing Crohn's disease

AIM

To characterize radiological and clinical factors associated with subsequent surgical intervention in Crohn’s disease (CD) patients with intra-abdominal fistulae.

METHODS

From a cohort of 1244 CD patients seen over an eight year period (2006 to 2014), 126 patients were identified as having intra-abdominal fistulae, and included in the study. Baseline patient information was collected from the medical records. Imaging studies were assessed for: anatomic type and number of fistulae; diameter of the inflammatory conglomerate; length of diseased bowel; presence of a stricture with pre-stenotic dilatation; presence of an abscess; lymphadenopathy; and the degree of bowel enhancement. Multivariate analysis for the prediction of abdominal surgery was calculated via Generalized Linear Models.

RESULTS

In total, there were 193 fistulae in 132 patients, the majority (52%) being entero-enteric. Fifty-nine (47%) patients underwent surgery within one year of the imaging study, of which 36 (29%) underwent surgery within one month. Radiologic features that were associated with subsequent surgery included: multiple fistulae (P = 0.009), presence of stricture (P = 0.02), and an entero-vesical fistula (P = 0.01). Evidence of an abscess, lymphadenopathy, or intense bowel enhancement as well as C-reactive protein levels was not associated with an increased rate of surgery. Patients who were treated after the imaging study with combination immunomodulatory and anti-TNF therapy had significantly lower rates of surgery (P = 0.01). In the multivariate analysis, presence of a stricture [RR 4.5 (1.23-16.3), P = 0.02] was the only factor that increased surgery rate.

CONCLUSION

A bowel stricture is the only factor predicting an increased rate of surgery. Radiological parameters may guide in selecting treatment options in patients with fistulizing CD.

Patient optimization for surgery relating to Crohn's disease

The majority of patients with Crohn's disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohn's disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.

Efficacy of fibrin glue therapy for abscess-associated enteric fistulas

BACKGROUND

Abdominal abscess that result from bowel injury may require treatment with percutaneous drainage. In some cases, an abscess-associated fistula develops between the injured bowel and the drainage catheter. Fistulas that fail to resolve may require surgery; however, fibrin glue therapy (FGT) may be a suitable alternative.

METHODS

We retrospectively identified patients undergoing FGT for an abscess-associated enteric fistula between 2004 and 2015. Success was defined as closure of the fistula tract without need for additional intervention. A multivariable logistic regression analysis was utilized to identify factors associated with success.

RESULTS

We identified 34 patients with a median age of 54 (23-87) years and 24 (71 %) males. FGT was successful in 23 (67 %) patients. On multivariate analysis, a tract width less than 5 mm (OR 19.2, 95 % CI 1.7-214.5) and removal of the drain (OR 13.8, 95 % CI 1.2-157.6) predicted FGT success. The time from initial FGT to resolution was significantly decreased for the patients who were successfully treated compared to those who failed 24 (14-38) days vs. 99 (71-175) days, respectively (p < 0.001).

CONCLUSIONS

Fibrin glue therapy for abscess-associated enteric fistula results in successful and accelerated healing in the majority of cases. Factors associated with successful fibrin glue therapy were identified.

Role of percutaneous abscess drainage in the management of young patients with Crohn disease

BACKGROUND

Intra-abdominal abscess is a common complication of Crohn disease in children. Prior studies, primarily in adults, have shown that percutaneous abscess drainage is a safe and effective treatment for this condition; however, the data regarding this procedure and indications in pediatric patients is limited.

OBJECTIVE

Our aim was to determine the success rate of percutaneous abscess drainage for abscesses related to Crohn disease in pediatric patients with a focus on treatment endpoints that are relevant in the era of biological medical therapy.

MATERIALS AND METHODS

We retrospectively reviewed 25 cases of patients ages ≤20 years with Crohn disease who underwent percutaneous abscess drainage. Technical success was defined as catheter placement within the abscess with reduction in abscess size on post-treatment imaging. Clinical success was defined as (1) no surgery within 1 year of drainage or (2) surgical resection following drainage with no residual abscess at surgery or on preoperative imaging. Multiple clinical parameters were analyzed for association with treatment success or failure.

RESULTS

All cases were classified as technical successes. Nineteen cases were classified as clinical successes (76%), including 7 patients (28%) who required no surgery within 1 year of percutaneous drainage and 12 patients (48%) who had elective bowel resection within 1 year. There was a statistically significant association between resumption of immunosuppressive therapy within 8 weeks of drainage and both clinical success (P < 0.01) and avoidance of surgery after 1 year (P < 0.01).

CONCLUSION

Percutaneous abscess drainage is an effective treatment for Crohn disease-related abscesses in pediatric patients. Early resumption of immunosuppressive therapy is statistically associated with both clinical success and avoidance of bowel resection, suggesting a role for percutaneous drainage in facilitating prompt initiation of medical therapy and preventing surgical bowel resection.

Preoperative Percutaneous Drainage of Spontaneous Intra-Abdominal Abscess in Patients With Crohn's Disease: A Meta-Analysis

GOALS

We aimed to compare clinical outcomes between percutaneous drainage (PD) with or without further elective surgery and initial surgery for patients with Crohn's disease (CD)-related spontaneous intra-abdominal abscess.

BACKGROUND

Intra-abdominal abscess is common in patients with CD leading to significant morbidity. The role of PD before abdominal surgery in patients with CD remains controversial.

STUDY

We performed a meta-analysis comparing PD and surgery as the initial approach to CD-related spontaneous intra-abdominal abscess. Overall complication and recurrent abscess were assessed. Subgroup analyses on initial PD were performed including preoperative PD and PD alone.

RESULTS

A total of 9 studies including 513 patients with CD-related spontaneous intra-abdominal abscesses were included. The overall complication rate was significantly higher in patients undergoing initial surgery compared with those undergoing initial PD [odds ratio (OR)=0.58; 95% confidence interval (CI), 0.35-0.96; P=0.03]. In a subgroup analysis, preoperative PD was associated with a significant reduction in overall complication (OR=0.44; 95% CI, 0.23-0.83; P=0.01) as compared with initial surgery. The risk for recurrent abscess was higher in patients who underwent PD alone than those who underwent initial surgery (OR=2.16; 95% CI, 1.03-4.54; P=0.04). No significance difference in postoperative recurrent abscess was found between preoperative PD group and initial surgery group.

CONCLUSION

Although abdominal surgery appeared to be inevitable in the majority of the patients with CD who develop intra-abdominal abscess, preoperative PD may decrease overall complication after surgery.

The role of CT-guided percutaneous drainage of loculated air collections: an institutional experience

OBJECTIVE

The purpose of this study is to describe our experience with the role of CT-guided percutaneous drainage of loculated intra-abdominal collections consisting entirely of gas.

MATERIALS AND METHODS

An IRB-approved retrospective study analyzing patients with air-only intra-abdominal collections over an 8-year period was undertaken. Seven patients referred for percutaneous drainage were included. Size of collections, subsequent development of fluid, and microbiological yield were determined. Clinical outcome was also analyzed.

RESULTS

Out of 2835 patients referred for percutaneous drainage between 2004 and 2012, seven patients (5M, 2F; average age 63, range 54-85) met criteria for inclusion with CT showing air-only collections. Percutaneous drain placement (five 8 Fr, one 10 Fr, and one 12 Fr) using Seldinger technique was performed. Four patients (57%) had recently undergone surgery (2 Whipple, 1 colectomy, 1 hepatic resection) while two (29%) had a remote surgery (1 abdominoperineal resection, 1 sigmoidectomy). Despite the lack of detectable fluid on the original CT, 6 patients (86%) had air and fluid aspirated at drainage, 5 (83%) of the aspirates developed positive microbacterial cultures. Four patients (57%) presented with fever at the time of the initial scan, all of whom had positive cultures from aspirated fluid. Four patients (57%) had leukocytosis, all of whom had positive cultures from aspirated fluid.

CONCLUSIONS

Although relatively rare in occurrence, patients with air-only intra-abdominal collections with signs of infection should be considered for percutaneous management similar to that of conventional infected fluid collections. Although fluid is not visible on CT, these collections can produce fluid that contains organisms.

Comparative evaluation of sump drainage by trocar puncture, percutaneous catheter drainage versus operative drainage in the treatment of Intra-abdominal abscesses: a retrospective controlled study

Background

Intra-abdominal and pelvic abscesses are common and result from various illnesses. Percutaneous drainage applies limitedly to well-localized abscesses with appropriate density while surgical drainage usually causes significant physiological disturbance. We herein illustrated an innovative choice “sump drainage with trocar puncture” for the management of intra-abdominal abscesses and compare it with conventional percutaneous and surgical drainage in terms of clinical outcomes and prognosis.

Methods

Medical records of a total of 75 patients with abscesses were retrospectively retrieved and scrutinized. Data consisted of demographics, abscesses characteristics and treatment outcomes including postoperative complication, duration of hospitalization, postoperative recurrence of abscesses, subsequent surgery, ultimate stoma creation and survival rate. All enrolled patients were divided into trocar group (n = 30), percutaneous group (n = 20) and surgical group (n = 25) according to the therapeutic modalities. One-way ANOVA and t-test with Welch’s correction were used in continuous variables, and Chi-squared test as well as Fisher’s exact test for categorical variables. The cumulative incidence of subsequent surgery and ultimate stoma creation was also indicated by the Kaplan–Meier method and compared by log-rank test.

Results

The risk of ultimate stoma creation (p = 0.0069) and duration of postoperative hospitalization (p = 0.0077) were significantly decreased in trocar group compared with the surgical group. Patients receiving trocar puncture also tended to be less likely to have subsequent surgery (p = 0.097). Patients in trocar group displayed a lower rate of postoperative complication than the percutaneous (p = 0.0317) and surgical groups (p = 0.0175). As for Kaplan–Meier analysis, the cumulative incidence of ultimate stoma creation of the patients using sump drainage was also significantly different among three groups during follow-up period (p = 0.011).

Conclusion

This novel technique “sump drainage by trocar puncture” could produce better clinical outcomes and prognosis than conventional percutaneous drainage and surgical intervention. It might become an optimal choice in the management of intra-abdominal abscesses in the future.

Outcomes of initial medical compared with surgical strategies in the management of intra-abdominal abscesses in patients with Crohn's disease: a meta-analysis

BACKGROUND

Several studies have also evaluated the efficacy of initial medical management compared with initial surgical management strategies with regard to abscess resolution with variable results.

OBJECTIVE

The aim of this study is to evaluate the efficacy of initial medical management compared with surgical management of Crohn's disease (CD)-related intra-abdominal abscesses.

DATA SOURCES

A comprehensive search of multiple databases (MEDLINE/PubMed, Cochrane databases, CINAHL, Scopus, and Google Scholar) was performed in August 2014.

STUDY SELECTION

All studies on adults comparing initial surgical versus medical approaches to treat CD-related abscesses were included.

MAIN OUTCOMES MEASURED

The durability of abscess resolution and rate of stoma creation between the groups undergoing initial surgical versus medical approaches were compared.

RESULTS

The pooled analysis of the nine studies including a total 603 patients showed an overall rate of abscess resolution were 56.6% in the medical group compared with 80.7% in the surgical group. There was over three-fold higher chance of achieving abscess resolution when an initial surgical strategy was used at the time of abscess diagnosis compared with the medical strategy (odds ratio 3.44, 95% confidence interval: 1.80, 6.58, P<0.001). The number needed to treat using the initial surgical approach to prevent a recurrent abscess was four patients.

LIMITATIONS

All included studies were retrospective case series with potential clinical confounders not fully accounted in the analysis.

CONCLUSION

Initial surgical management appears to be superior to medical management in patients with CD-related intra-abdominal abscesses. Though all the included studies in this meta-analysis were retrospective, this meta-analysis is likely the strongest level of evidence with regard to the management of CD-related abscesses, given that a randomized-control trial may not be feasible given the low rate of abscess development in CD.

Abdominal abscess in Crohn's disease: multidisciplinary management

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.

Comparison of the long-term outcome of two therapeutic strategies for the management of abdominal abscess complicating Crohn's disease: percutaneous drainage or immediate surgical treatment

AIM

The management of abdominal abscesses complicating Crohn's disease is complex and involves a difficult choice between medical, radiological and surgical procedures. The long-term outcome was compared for two strategies for the management of abdominal abscess: percutaneous drainage (PD) followed by rescue surgery in the case of failure vs direct immediate surgery (IS). We also compared the results of IS with surgery performed after PD failure.

METHODS

We retrospectively identified 44 patients with Crohn's disease with an abdominal abscess from January 2000 to December 2009. Therapeutic success was defined as abscess resolution and no reappearance within 1 year of follow-up.

RESULTS

The first therapeutic approach was PD in 22 cases and IS in the other 22 cases. IS had a higher therapeutic success rate than PD (95.5% vs 27.2% respectively; P < 0.001). PD was the only independent variable related to treatment failure in the multivariate analysis after adjustment for possible confounders such as abscess size, multilocularity, presence of fistula and corticosteroid use (OR 88.26, 95% CI 7.38-1055.36; P < 0.001). Surgery after failure of PD (n = 16) was associated with longer total hospitalization (56.12 ± 35.89 vs 27.52 ± 15.11 days; P = 0.017) and longer postoperative stay (44.0 ± 83.7 vs 14.3 ± 30 days; P = 0.179) and needed a second operation more often (5/16, 31% vs 1/22, 4.5%; P = 0.065) than IS.

CONCLUSIONS

Percutaneous drainage provided durable abscess resolution in only one-third of the patients compared with more than 90% of those treated with IS. In addition, surgery performed after PD failure results in a poorer outcome than IS.

Review article: optimal preparation for surgery in Crohn's disease

BACKGROUND

One-third of Crohn's disease (CD) patients will undergo abdominal surgery within the first 5 years of diagnosis.

AIM

To review the available evidence on pre-operative optimisation of CD patients.

METHODS

The literature regarding psychological support, radiological imaging, abdominal abscess management, nutritional support, thromboembolic prophylaxis and immunosuppression in the perioperative setting was reviewed.

RESULTS

For diagnosis of fistulas, abscesses and stenosis, ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) have a high diagnostic accuracy. Under either CT or US guidance, it is possible to perform abscess percutaneous drainage (PD), which, with systemic antibiotic therapy, should be the first-line approach to intra-abdominal abscesses. CD patients with weight loss <10% within the last 3-6 months, body mass index < 18.5 kg/m(2) and/or albumin levels <30 g/L, are at an increased risk of post-operative complications. Pre-operative nutritional support should be used in these patients. IBD patients undergoing surgery have a higher risk of venous thromboembolic disease than patients with colorectal cancer, and current guidelines recommend that they should receive prophylaxis with heparin. Whether the use of anti-TNF agents before surgery increases the likelihood of post-operative complications, is the subject of much debate. To date, cumulative evidence from most studies (all retrospective) suggests that there is no such risk increment. Prospective studies are necessary to firmly establish this conclusion.

CONCLUSIONS

Preparation for surgery requires close interaction between surgeons, gastroenterologist, radiologists, psychologists and the patient. Correct pre-operative planning of surgical treatment has a major impact on the outcome of such treatment.

Ciprofloxacin usage and bacterial resistance patterns in Crohn's disease patients with abscesses

BACKGROUND

Ciprofloxacin is the antibiotic most frequently used in the treatment of Crohn's disease (CD). We attempted to identify the microorganisms present in CD-related intra-abdominal abscesses, their ciprofloxacin resistance patterns, and the clinical impact.

METHODS

Microorganisms, their ciprofloxacin resistance, and clinical outcomes were retrospectively analyzed in 78 CD patients with intra-abdominal abscesses, who underwent percutaneous drainage between March 1991, and November 2011.

RESULTS

The median time from diagnosis of CD to abscess drainage was 59.5 months (range, 1 to 178 mo). As for bacteriology, the no-growth proportion was 38.5% (n=30), and 69 microorganisms belonging to 11 genera were isolated from the other 48 (61.5%) patients. Of the 69 microorganisms, 65 were bacteria, including 30 (43.4%) gram-positive, 28 (40.6%) gram-negative aerobes, 7 (10.1%) gram-negative anaerobes, and 4 (4.1%) fungi. Streptococci spp. (25, 36.2%) were the most common bacteria, followed by Escherichia coli (18, 26.1%). Nineteen of the 28 gram-negative aerobes (67.9%) were resistant to ciprofloxacin, including 14 of 18 (77.8%) E. coli isolates. When we compared clinical characteristics and treatment outcomes in 17 patients with ciprofloxacin-resistant and 8 with ciprofloxacin-sensitive bacteria, we found that disease duration from diagnosis to drainage (97.2 vs. 50.7 mo, P=0.03) and median length of hospitalization (40 vs. 31 d, P=0.03) was significantly longer in the former.

CONCLUSIONS

When gram-negative aerobes were isolated from abscesses in CD patients, more than two thirds were resistant to ciprofloxacin. Providers should consider this high rate of ciprofloxacin resistance when choosing first-line antibiotic treatment for CD-related intra-abdominal abscesses.

Use of intra-abdominal drains

The use of drains in colorectal surgery has been a subject of debate for several decades. Prophylactic drainage of the peritoneal cavity has become less popular in recent years. This change is due to several studies demonstrating that intraperitoneal drains do not adequately drain the peritoneal cavity and do not prevent or contain anastomotic leaks. Percutaneous drain placement has become the standard of care for patients with intra-abdominal abscesses. Selected anastomotic leaks in the stable patient can also be managed with percutaneous drains. In this article, the authors review in detail the use of drains and the literature to support their use in our everyday practice.

Magnetic resonance enterography in evaluation and management of children with Crohn's disease

The role of radiologic evaluation in Crohn's disease (CD) has undergone a recent paradigm shift in which the radiologist adds value to the multidisciplinary team by longitudinally assessing therapeutic response and identifying treatment-modifying subtypes, such as fibrostenotic or fistulizing disease. Magnetic resonance enterography (MRE) has become the primary imaging modality used. The combination of multiplanar, multiparametric, and multiphasic contrast-enhanced imaging with the high spatial resolution and very high tissue contrast of MR imaging allows for detailed evaluation of intra-abdominal pathology, without the risk of cumulative radiation exposure. MRE provides the benefit of a complete evaluation of mural, extramural, and even extraintestinal manifestations and complications of CD in a single examination. Cine motility sequences and diffusion-weighted imaging may further increase sensitivity and specificity. MRE represents an ideal imaging modality for initial evaluation, assessment of therapeutic response, and evaluation of complications in patients with CD.

Comparative Outcomes of Trocar Puncture With Sump Drain, Percutaneous Drainage, and Surgical Drainage in the Management of Intra-abdominal Abscesses in Crohn’s Disease

Background. Intra-abdominal abscess is a common complication in Crohn’s disease (CD). Traditional percutaneous catheter drainage (PCD) and surgical intervention could not obtain satisfactory results in some cases. We herein demonstrate a novel management option and compare it with traditional strategies. Methods. A total of 77 patients were retrospectively collected into 3 groups. Postoperative complication, postoperative recurrence of abscess, subsequent surgery, ultimate stoma creation rate, and survival rate were analyzed. Results. Patients were divided into the trocar group (n = 21), PCD group (n = 25), and surgery group (n = 31). The incidences of postoperative complication as well as the incidence of recurrent abscess were lowest in trocar group, and ultimate stoma creation rate was highest in the surgery group. Subsequent surgery after initial intervention and survival rate during the follow-up period were similar among the 3 groups. Conclusions. Trocar puncture with sump drain had lower incidence of postoperative complication, postoperative recurrence of abscess, and ultimate stoma creation compared with conventional PCD and surgical interventions. This novel technique might be an optimal option in the management of intra-abdominal abscesses in CD.

Intra-abdominal abscess drainage: interval to surgery

Placement of percutaneous drainage catheters has become first-line therapy in the treatment of patients with intra-abdominal abscesses. Catheters can be used to avoid surgical intervention or to improve surgical outcomes. This article discusses the current evidence describing the optimal interval between percutaneous drainage procedures and surgery, focusing on patients with Crohn's disease, appendicitis, and diverticulitis.

Surgery and diagnostic imaging in abdominal Crohn's disease

Surgery is well-established option for the treatment of Crohn's disease that is refractory to medical therapy and for complications of the disease, including strictures, fistulas, abscesses, bleeding that cannot be controlled endoscopically, and neoplastic degeneration. For a condition like Crohn's disease, where medical management is the rule, other indications for surgery are considered controversial, because the therapeutic effects of surgery are limited to the resolution of complications and the rate of recurrence is high, especially at sites of the surgical anastomosis. In the authors' opinion, however, surgery should not be considered a last-resort treatment: in a variety of situations, it should be regarded as an appropriate solution for managing this disease. Based on a review of the literature and their own experience, the authors examine some of the possibilities for surgical interventions in Crohn's disease and the roles played in these cases by diagnostic imaging modalities.

Treatment of intra-abdominal abscesses in Crohn's disease: a nationwide analysis of patterns and outcomes of care

BACKGROUND

Abdominal abscesses are a common complication in Crohn's disease (CD). Percutaneous drainage of such abscesses has become increasingly popular and may deliver outcomes comparable to surgical treatment; however, such comparative data are limited from single-center studies. There have been no nationally representative studies comparing different treatment modalities for abdominal abscesses.

METHODS

We identified all adult CD-related non-elective hospitalizations from the Nationwide Inpatient Sample 2007 that were complicated by an intra-abdominal abscess. Treatment modality was categorized into 3 strata-medical treatment alone, percutaneous drainage, and surgery. We analyzed the nationwide patterns in the treatment and outcomes of each treatment modality and examined for patient demographic, disease, or hospital-related disparities in treatment and outcome.

RESULTS

There were an estimated 3,296 hospitalizations for abdominal abscesses in patients with CD. Approximately 39 % were treated by medical treatment alone, 29 % with percutaneous drainage, and 32 % with surgery with a significant increase in the use of percutaneous drainage since 1998 (7 %). Comorbidity burden, admission to a teaching hospital, and complicated Crohn's disease (fistulae, stricture) were associated with non-medical treatment. Use of percutaneous drainage was more common in teaching hospitals. Mean time to percutaneous drainage and surgical treatment were 4.6 and 3.3 days, respectively, and early intervention was associated with significantly shorter hospitalization.

CONCLUSIONS

We describe the nationwide pattern in the treatment of abdominal abscesses and demonstrate an increase in the use of percutaneous drainage for the treatment of this subgroup. Early treatment intervention was predictive of shorter hospitalization.

Spontaneous abdominopelvic abscess as an initial manifestation of Crohn's disease: a retrospective cohort review

OBJECTIVE

The study aimed to compare the clinical characteristics of abdominopelvic (AP) abscess in patients with and without newly diagnosed Crohn's disease (CD).

METHODS

We investigated 91 consecutive patients with AP abscess (14 newly diagnosed with CD) from January 2001 to December 2010. The clinical, radiological, microbiological and pathological features and patients' outcomes were evaluated.

RESULTS

Patients with newly diagnosed CD were younger (42.5 vs. 57.9 years, P = 0.004), more associated with fever (50.0% vs. 13.0%, P = 0.004) and weight loss (21.4% vs. 3.9%, P = 0.045), and normoglycemic (5.2 mmol/L vs. 6.7 mmol/L, P = 0.001). Their abscesses, located predominantly at the paracolic gutter region (P = 0.002) were associated with fistulae (P = 0.001) and caused by transmural bowel wall inflammation. More patients in the CD group required temporarily parenteral nutritional support (P = 0.000) and had a longer hospital stay (P = 0.045) and a higher local recurrent rate (P = 0.000).

CONCLUSION

AP abscesses associated with newly diagnosed CD display distinct clinical behavior with a high risk of local recurrence.