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

4. Pathogenesis of abscess

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

6. Rectal Abscess

7. Thick walled pelvic abscess

8. Intra abdominal abscess

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

13. Outcome of surgery and PAD

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

15. Famous people with Crohns

16. Thanks for patient listening