Basic structure of hair and hair growth cycle.pptx
Outcome of abscess treatment in Crohn's disease
1. 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
2. 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
5. 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
9. 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
10. 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
12. 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
14. 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