|
1
|
Alshammary SA, Boumarah DN. Hepatic Abscess in Inflammatory Bowel Disease: A Systematic Scoping Review of an Overlooked Entity. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2023; 11:267-274. [PMID: 37970456 PMCID: PMC10634461 DOI: 10.4103/sjmms.sjmms_545_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 02/24/2023] [Accepted: 07/05/2023] [Indexed: 11/17/2023]
Abstract
Background Liver abscess is one of the hepatobiliary manifestations of inflammatory bowel disease (IBD) that has been scarcely described in the literature. Objectives To conduct a scoping review to provide a detailed description of the occurrence of hepatic abscess in patients with IBD and summarize the observed clinical features. Methodology Searches were carried out using relevant keywords in Medline (via PubMed) and Web of Science from inception until June 13, 2022. Only articles that reported the occurrence of hepatic abscess in patients with IBD were included. Results Forty-eight publications (40 case reports and 8 case series) were included, representing 73 patients with IBD who were radiologically or intraoperatively diagnosed with hepatic abscess. Patients with Crohn's disease were more predisposed to developing hepatic abscess than patients with ulcerative colitis (79.5% vs. 20.5%, respectively). Furthermore, pyogenic liver abscess was found to be more prevalent (57.9%) compared with aseptic (38.7%) and amebic (3.2%) abscesses. No clear relation was found between death or prolonged hospital stay in terms of the clinical presentation or management plan, as mortality was reported in different age groups with different managements. Conclusion To date, there is no consensus regarding the appropriate management of hepatic abscess as an extraintestinal manifestation of IBD. However, the condition shares several features with liver abscess diagnosed among the general population.
Collapse
Affiliation(s)
- Shadi Abdullah Alshammary
- Department of Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Dhuha Nahar Boumarah
- Department of Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| |
Collapse
|
|
2
|
Dong S, Chen B, Zhang J. Study on the factors influencing the prognosis after perianal abscess surgery. BMC Gastroenterol 2023; 23:334. [PMID: 37759161 PMCID: PMC10537581 DOI: 10.1186/s12876-023-02959-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVE To study the influence of clinical characteristics and diagnosis and treatment methods of perianal abscess on postoperative recurrence or formation of anal fistula to provide a basis for selecting appropriate surgical and inspection methods for clinical treatment of perianal abscess in the future. METHODS The clinical data of 394 patients with perianal abscesses were collected, the influencing factors were investigated, and univariate analysis and multivariate logistic regression analysis were performed to further determine the risk factors affecting the prognosis of perianal abscess. RESULTS The results showed that the rate of preoperative blood routine results in the uncured group was higher (51.16%) than in the cured group (35.61%); the rate of high abscess space in the uncured group (23.26%) was higher than in the cured group (9.11%); the proportion of patients in the uncured group who underwent magnetic resonance imaging (MRI) before surgery (27.90%) was lower than in the cured group (45.30%); the proportion of patients in the uncured group who underwent simple drainage (51.16%) was higher than in the cured group (28.49%). The two groups had significant differences in perineal MRI examination, surgical method, preoperative blood routine, and abscess space (p = 0.030, p = 0.002, p = 0.047 and p = 0.010, respectively). Based on the results of univariate analysis and multivariate logistic regression analysis, the extent of the abscess cavity (OR = 2.544, 95%CI = 1.087-5.954, p = 0.031) and the surgical method (OR = 2.180, 95%CI = 1.091-4.357, p = 0.027) were independent influencing factors for postoperative recurrence of perianal abscess or anal fistula. CONCLUSION Preoperative assessment of the abscess range and precise intraoperative methods to resolve the infection of the abscess glands in the internal mouth can effectively improve the cure rate.
Collapse
Affiliation(s)
- Shujiang Dong
- Department of anus-intestines, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, No. 68 Gehu Middle Road, Wujin District, 213000, 213000, Changzhou, China.
| | - Bingxue Chen
- Department of anus-intestines, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, No. 68 Gehu Middle Road, Wujin District, 213000, 213000, Changzhou, China
| | - Jian Zhang
- Department of Medical Imaging, Changzhou Second People's Hospital Affiliated to Nanjing Medical University, Changzhou, 213000, China
| |
Collapse
|
|
3
|
Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2022; 65:964-985. [PMID: 35732009 DOI: 10.1097/dcr.0000000000002473] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Pamela L Burgess
- Department of Surgery, Uniformed Services University of the Health Sciences, Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Jennifer S Davids
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Mark Y Sun
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| |
Collapse
|
|
4
|
Abstract
Intra-abdominal and anorectal abscesses are common pathologies seen in both inpatient and outpatient settings. To decrease morbidity and mortality, early diagnosis and treatment are essential. After adequate drainage via a percutaneous or incisional approach, patients need to be monitored for worsening symptoms or recurrence and evaluated for the underlying condition that may have contributed to abscess formation.
Collapse
Affiliation(s)
- Dakota T Thompson
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA
| | - Jennifer E Hrabe
- Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.
| |
Collapse
|
|
5
|
Abstract
Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in progressive tissue damage, which can result in strictures, fistulae, and abscesses formation. The triggering mechanism is thought to be in the fecal stream, and diversion of this fecal stream is sometimes required to control disease when all other avenues of medical and surgical management have been exhausted. Fecal diversion can be temporary or permanent with the indications being defunctioning a high-risk anastomosis, as a result of a surgical complication, for disease control, or due to severe colonic, rectal, or perianal disease. The incidence of ostomy formation in CD has increased epidemiologically over time. The primary indication for ostomy formation is severe perianal fistulizing disease. However, while 64% of patients have an early clinical response after diversion for refractory perianal CD, restoration of bowel continuity is attempted in only 35% of patients, and is successful in only 17%. The current review discusses the indications for ostomy creation in complex CD, strategies for procedure selection, and patient outcomes.
Collapse
Affiliation(s)
- John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.,Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| |
Collapse
|
|
6
|
Hain E, Maggiori L, Orville M, Tréton X, Bouhnik Y, Panis Y. Diverting Stoma for Refractory Ano-perineal Crohn's Disease: Is It Really Useful in the Anti-TNF Era? A Multivariate Analysis in 74 Consecutive Patients. J Crohns Colitis 2019; 13:572-577. [PMID: 30452620 DOI: 10.1093/ecco-jcc/jjy195] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Faecal diversion [FD] can be proposed in patients with refractory anoperineal Crohn's disease [APCD]. This study aimed to assess long-term results of this strategy, following the advent of the anti-tumour necrosis factor [TNF] era. METHODS All patients who underwent FD for refractory APCD between 2005 and 2017 were included, excluding patients with a history of ileal pouch-anal anastomosis. A multivariate analysis regarding absence of stoma reversal [SR] was performed. RESULTS A total of 65 consecutive patients who underwent FD for APCD (comprising anoperineal fistula [n = 40, 62%], rectovaginal fistula [n = 21, 32%], fissures and/or ulceration [n = 9, 14%], and/or anal stricture [n = 5, 8%]) were included. At the time of FD, 34 patients [52%] presented with small bowel Crohn's disease [CD] involvement, 29 [45%] with colonic involvement, and 19 [29%] with rectal involvement. Following FD, 54 patients [83%] were treated with anti-TNF therapy, prescribed for isolated APCD [n = 10, 15%] or luminal CD with APCD [n = 44, 68%]. After a mean follow-up of 49 ± 29 [7-120] months, SR was not possible in 32 patients [49%], including 17 patients [26%] requiring a subsequent proctectomy with abdominoperineal excision. In multivariate analysis, rectal CD involvement was the only independent factor associated with a reduced rate of SR (odds ratio: 4.0 [1.153-14.000]; p = 0.029), and anti-TNF therapy had no impact on SR rate. CONCLUSIONS FD can be performed in selected patients with refractory APCD, to avoid abdominoperineal resection. However, this strategy should be proposed with caution in patients presenting with rectal CD involvement. Anti-TNF therapy has no impact on SR rate.
Collapse
Affiliation(s)
- Elisabeth Hain
- Department of Colorectal Surgery, Beaujon Hospital, University Denis Diderot [Paris VII], Clichy, France
| | - Léon Maggiori
- Department of Colorectal Surgery, Beaujon Hospital, University Denis Diderot [Paris VII], Clichy, France
| | - Marion Orville
- Department of Colorectal Surgery, Beaujon Hospital, University Denis Diderot [Paris VII], Clichy, France
| | - Xavier Tréton
- Department of Gastroenterology, Inflammatory Bowel Disease, and Nutritive Assistance, Beaujon Hospital, University Denis Diderot [Paris VII], Clichy, France
| | - Yoram Bouhnik
- Department of Gastroenterology, Inflammatory Bowel Disease, and Nutritive Assistance, Beaujon Hospital, University Denis Diderot [Paris VII], Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, University Denis Diderot [Paris VII], Clichy, France
| |
Collapse
|
|
7
|
Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, Calabrese E, Baumgart DC, Bettenworth D, Borralho Nunes P, Burisch J, Castiglione F, Eliakim R, Ellul P, González-Lama Y, Gordon H, Halligan S, Katsanos K, Kopylov U, Kotze PG, Krustinš E, Laghi A, Limdi JK, Rieder F, Rimola J, Taylor SA, Tolan D, van Rheenen P, Verstockt B, Stoker J. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis 2019; 13:144-164. [PMID: 30137275 DOI: 10.1093/ecco-jcc/jjy113] [Citation(s) in RCA: 1129] [Impact Index Per Article: 188.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Christian Maaser
- Outpatients Department of Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Andreas Sturm
- Department of Gastroenterology, DRK Kliniken Berlin I Westend, Berlin, Germany
| | | | - Torsten Kucharzik
- Department of Internal Medicine and Gastroenterology, Hospital Lüneburg, Lüneburg, Germany
| | - Gionata Fiorino
- Department of Gastroenterology, Humanitas Clinical and Research Institute, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, Valiant Clinic & American Hospital, Dubai, UAE
| | - Emma Calabrese
- Department of Systems Medicine, University of Rome, Tor Vergata, Italy
| | - Daniel C Baumgart
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Dominik Bettenworth
- Department of Medicine B, Gastroenterology and Hepatology, University Hospital Münster, Münster, Germany
| | - Paula Borralho Nunes
- Department of Anatomic Pathology, Hospital Cuf Descobertas; Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Johan Burisch
- Department of Gastroenterology, North Zealand University Hospital; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - Rami Eliakim
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Pierre Ellul
- Department of Medicine, Mater Dei Hospital, Msida, Malta
| | - Yago González-Lama
- Department of Gastroenterology, University Hospital Puerta De Hierro, Majadahonda [Madrid], Spain
| | - Hannah Gordon
- Department of Gastroenterology, Royal London Hospital, London, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London, London, UK
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel
| | - Paulo G Kotze
- Colorectal Surgery Unit, Catholic University of Paraná [PUCPR], Curitiba, Brazil
| | - Eduards Krustinš
- Department of of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Andrea Laghi
- Department of Clinical and Surgical Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Jimmy K Limdi
- Department of Gastroenterology, Pennine Acute Hospitals NHS Trust, Manchester; Manchester Academic Health Sciences Centre, University of Manchester, UK
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jordi Rimola
- Department of Radiology, Hospital Clínic Barcelona, Barcelona, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, University College London, London, UK
| | - Damian Tolan
- Clinical Radiology, St James's University Hospital, Leeds, UK
| | - Patrick van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven and CHROMETA - Translational Research in Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Academic Medical Center [AMC], University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
|
8
|
Packing versus mushroom catheters following incision and drainage in anorectal abscess. Ir J Med Sci 2019; 188:1343-1348. [PMID: 30675692 DOI: 10.1007/s11845-018-01958-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/18/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE Management of anorectal abscess is traditionally by incision and drainage with packing. This study assessed the use of mushroom catheters compared with packing of anorectal abscess after incision and drainage in adults. Placement of a mushroom catheter to allow ongoing drainage of the cavity may have advantages by eliminating the need for painful dressing changes. METHODS This was a retrospective observational study. Following ethical approval, a chart review of 167 patients treated for anorectal abscess with either packing or mushroom catheter at Cork University Hospital from 2010 to 2015 was performed. Treatment decision was based on individual surgeon preference. Outcome measures included recurrence and fistula development. Telephone follow-up was also performed to assess patient satisfaction and quality of life (EQ-5D-3L). RESULTS One hundred and twenty-nine patients were treated with incision and drainage with packing, and 38 patients were treated with mushroom catheter. There was no statistically significant difference in recurrence (p = 0.691) or fistula development (p = 0.299) between the groups. Twenty-three patients had Crohn's disease, 17 patients had diabetes and 66 patients were smokers. There was no statistically significant difference in recurrence or fistula development between the treatment groups in Crohn's (p = 0.493), diabetics (p = 0.949) and smokers (p = 0.275). On average, patients treated with mushroom catheter reported a statistically significant higher satisfaction score (9.2 ± 1.0) than patients treated with packing (7.6 ± 1.8, p = 0.013). CONCLUSION Mushroom catheter drainage of anorectal abscesses is a safe alternative to traditional packing and results in higher patient satisfaction. This study provides a rationale for a future randomised controlled trial.
Collapse
|
|
9
|
Ballard DH, Sangster GP, Tsai R, Naeem S, Nazar M, D'Agostino HB. Multimodality Imaging Review of Anorectal and Perirectal Diseases with Clinical, Histologic, Endoscopic, and Operative Correlation, Part II: Infectious, Inflammatory, Congenital, and Vascular Conditions. Curr Probl Diagn Radiol 2018; 48:563-575. [PMID: 30154030 DOI: 10.1067/j.cpradiol.2018.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 07/20/2018] [Accepted: 07/25/2018] [Indexed: 12/16/2022]
Abstract
A broad spectrum of pathology affects the rectum, anus, and perineum, and multiple imaging modalities are complementary to physical examination for assessment and treatment planning. In this pictorial essay, correlative imaging, endoscopic, pathologic, and operative images are presented for a range of rectal, perirectal, and perineal disease processes, including infectious/inflammatory, traumatic, congenital/developmental, vascular, and miscellaneous conditions. Key anatomic and surgical concepts are discussed, including radiological information pertinent for surgical planning, and current operative approaches of these anatomic spaces to assist radiologists in comprehensive reporting for gastroenterologists and surgeons.
Collapse
Affiliation(s)
- David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Guillermo P Sangster
- Department of Radiology, Louisiana State University Health Shreveport, Shreveport, LA..
| | - Richard Tsai
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Sana Naeem
- Department of Radiology, Louisiana State University Health Shreveport, Shreveport, LA
| | - Miguel Nazar
- Department of Radiology, Hospital Aleman, Buenos Aires, Argentina
| | - Horacio B D'Agostino
- Department of Radiology, Louisiana State University Health Shreveport, Shreveport, LA
| |
Collapse
|
|
10
|
Abstract
Anal complaints are very common in the general population and are caused by a variety of disorders mostly benign in nature. The aim of this article is to provide the radiologist with a detailed description of the MRI anatomy and technique, and an overview of the various diseases most commonly presenting with anal pain, by descriptions and illustrative examples of MRI features of each entity.
Collapse
Affiliation(s)
- Ayşe Erden
- Department of Radiology, School of Medicine, Ankara University, Talatpaşa Bulvarı, Sıhhiye, 06100, Ankara, Turkey.
| |
Collapse
|
|
11
|
Bermejo F, Guerra I, Algaba A, López-Sanromán A. Pharmacological Approach to the Management of Crohn's Disease Patients with Perianal Disease. Drugs 2018; 78:1-18. [PMID: 29139091 DOI: 10.1007/s40265-017-0842-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perianal localization of Crohn's disease involves significant morbidity, affects quality of life and results in an increased use of healthcare resources. Medical and surgical therapies contribute to its management. The objective of this review is to address the current understanding in the management of perianal Crohn's disease, with the main focus in reviewing pharmacological therapies, including stem cells. In complex fistulas, once local sepsis has been controlled by surgical drainage and/or antibiotics, anti-TNF drugs (infliximab, adalimumab) are the first-line therapy, with or without associated immunomodulators. Combining surgery and anti-TNF therapy has additional benefits for healing. However, response is inadequate in up to half of cases. A possible role of new biological drugs in this context (vedolizumab, ustekinumab) is an area of ongoing investigation, as is the local application of autologous or allogeneic mesenchymal stem cells. These are non-hematopoietic multipotent cells with anti-inflammatory and immunomodulatory properties, the use of which may successfully treat refractory patients, and seem to be a promising and safe alternative to achieving fistula healing in Crohn's disease, without known systemic effects.
Collapse
Affiliation(s)
- Fernando Bermejo
- Department of Gastroenterology, University Hospital of Fuenlabrada, Madrid, Spain.
- Department of Medicine and Surgery, Universidad Rey Juan Carlos, Madrid, Spain.
| | - Iván Guerra
- Department of Gastroenterology, University Hospital of Fuenlabrada, Madrid, Spain
| | - Alicia Algaba
- Department of Gastroenterology, University Hospital of Fuenlabrada, Madrid, Spain
| | - Antonio López-Sanromán
- Department of Gastroenterology and Hepatology, University Hospital Ramón y Cajal, Madrid, Spain
| |
Collapse
|
|
12
|
Scoville EA, Schwartz DA. Endoscopy in inflammatory bowel disease: advances in disease management. Gastrointest Endosc 2017; 86:952-961. [PMID: 28886962 DOI: 10.1016/j.gie.2017.08.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 08/29/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Elizabeth A Scoville
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David A Schwartz
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
|
13
|
Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
|
14
|
Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum 2016; 59:1117-1133. [PMID: 27824697 DOI: 10.1097/dcr.0000000000000733] [Citation(s) in RCA: 222] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
|
15
|
Aguilera-Castro L, Ferre-Aracil C, Garcia-Garcia-de-Paredes A, Rodriguez-de-Santiago E, Lopez-Sanroman A. Management of complex perianal Crohn's disease. Ann Gastroenterol 2016; 30:33-44. [PMID: 28042236 PMCID: PMC5198245 DOI: 10.20524/aog.2016.0099] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 09/21/2016] [Indexed: 12/11/2022] Open
Abstract
Patients with Crohn's disease often develop perianal disease, successfully managed in most cases. However, its most aggressive form, complex perianal disease, is associated with high morbidity and a significant impairment in patients' quality of life. The aim of this review is to provide an updated approach to this condition, reviewing aspects of its epidemiology, diagnosis and therapeutic alternatives. Emerging treatment options are also discussed. A multidisciplinary assessment of these patients with a coordinated medical and surgical approach is crucial.
Collapse
Affiliation(s)
- Lara Aguilera-Castro
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
| | - Carlos Ferre-Aracil
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
| | - Ana Garcia-Garcia-de-Paredes
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
| | - Enrique Rodriguez-de-Santiago
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
| | - Antonio Lopez-Sanroman
- Gastroenterology and Hepatology Department, University Hospital Ramón y Cajal (affiliated with Universidad de Alcalá), Madrid, Spain
| |
Collapse
|
|
16
|
|
|
17
|
de Groof EJ, Sahami S, Lucas C, Ponsioen CY, Bemelman WA, Buskens CJ. Treatment of perianal fistula in Crohn's disease: a systematic review and meta-analysis comparing seton drainage and anti-tumour necrosis factor treatment. Colorectal Dis 2016; 18:667-75. [PMID: 26921847 DOI: 10.1111/codi.13311] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/18/2015] [Indexed: 12/13/2022]
Abstract
AIM The introduction of anti-tumour necrosis factor (anti-TNF; infliximab and adalimumab) has changed the management of Crohn's perianal fistula from almost exclusively surgical treatment to one with a much larger emphasis on medical therapy. The aim of this systematic review was to provide an overview of the success rates of setons and anti-TNF for Crohn's perianal fistula. METHOD Studies evaluating the effect of setons and anti-TNF on Crohn's perianal fistula were included. Studies assessing perianal fistula in children, rectovaginal and rectourinary fistulae were excluded. The primary end-point was the fistula closure rate. Partial closure and recurrence rates were secondary end-points. RESULTS Ten studies on seton drainage were included (n = 305). Complete closure varied from 13.6% to 100% and recurrence from 0% to 83.3%. In 34 anti-TNF studies (n = 1449), complete closure varied from 16.7% and 93% (partial closure 8.0-91.2%) and recurrence from 8.0% to 40.9%. Four randomized controlled trials (n = 1028) comparing anti-TNF with placebo showed no significant difference in complete or partial closure in meta-analysis (risk difference 0.12, 95% CI -0.06 to 0.30 and 0.09, 95% CI -0.23 to 0.41, respectively). Subgroup analysis (n = 241) showed a significant advantage for complete fistula closure with anti-TNF in two trials with follow-up > 4 weeks (46% vs 13%, P = 0.003 and 30% vs 13%, P = 0.03). Of four included cohort studies, two revealed a significant difference in response in favour of combined treatment (P = 0.001 and P = 0.014). CONCLUSION Closure and recurrence rates after seton drainage as well as anti-TNF vary widely. Despite a large number of studies, no conclusions can be drawn regarding the preferred strategy. However, combination therapy with (temporary) seton drainage, immunomodulators and anti-TNF may be beneficial in achieving perianal fistula closure.
Collapse
Affiliation(s)
- E J de Groof
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - S Sahami
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - C Lucas
- Department of Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - C Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - C J Buskens
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
|
18
|
|
|
19
|
Garcia-Granero A, Granero-Castro P, Frasson M, Flor-Lorente B, Carreño O, Espí A, Puchades I, Garcia-Granero E. Management of cryptoglandular supralevator abscesses in the magnetic resonance imaging era: a case series. Int J Colorectal Dis 2014; 29:1557-64. [PMID: 25339133 DOI: 10.1007/s00384-014-2028-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2014] [Indexed: 02/04/2023]
Abstract
AIM The aim of this study is to describe the diagnostic performance of magnetic resonance imaging in the management of supralevator abscess, regarding its origin, location, drainage route, subsequent treatment of the fistula, and long-term results. METHODS A retrospective case series including thirteen consecutive patients with cryptoglandular supralevator abscess treated between 2001 and 2011 at a colorectal unit of a tertiary referral center. A magnetic resonance imaging was performed in all patients before surgical drainage, and its usefulness in assessing supralevator abscess origin was analyzed. Short- and long-term results after drainage were also evaluated. RESULTS The final diagnosis of supralevator abscess and the location described in the magnetic resonance were confirmed intraoperatively in all patients. An ischiorectal origin was identified in nine patients, and perineal translevator drainage was performed placing a mushroom catheter through the ischiorectal or the postanal space. Four patients underwent secondary treatment of anal fistula: two rectal advancement flap and two non-cutting seton. In the other four patients, an intersphincteric origin was identified and transanal surgical drainage was performed placing a long-term mushroom catheter. Several weeks later, transanal unroofing of the residual cavity was performed and the fistula lay open to the anorectal lumen. In the long-term follow-up (median 61 months), only patients with supralevator abscess of ischiorectal origin in whom fistula was not subsequently treated presented a recurrence of the anal sepsis. CONCLUSIONS Magnetic resonance imaging seems essential to clarify the location of supralevator abscess, its origin, and choice of the right drainage route. Subsequent treatment of the fistula is necessary to avoid recurrence.
Collapse
Affiliation(s)
- Alvaro Garcia-Granero
- Department of General Surgery, Hospital Arnau de Vilanova, University of Valencia, C/Pizarro 5, 46004, Valencia, Spain,
| | | | | | | | | | | | | | | |
Collapse
|
|
20
|
Pellino G, Selvaggi F. Surgical treatment of perianal fistulizing Crohn's disease: from lay-open to cell-based therapy--an overview. ScientificWorldJournal 2014; 2014:146281. [PMID: 25431776 PMCID: PMC4241327 DOI: 10.1155/2014/146281] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 10/21/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Perianal Crohn's disease (CD) can be challenging. Despite the high incidence of fistulizing CD, literature lacks clear guidelines. Several medical, surgical, and combined treatment modalities have been proposed, but evidences are scarce. METHODS We searched the literature to assess the facets of perianal CD, with particular focus on complex fistulae. Disease epidemiology, classification, diagnosis, activity scoring systems, and medical-surgical treatments were assessed. RESULTS Perianal fistulizing CD is common, frequently associated with upper gastrointestinal and colorectal CD. Complex fistulas often require repeated treatments. Continence is a major concern when dealing with repeated procedures. A prudent pathway is to resolve active sepsis and to limit damages, delaying a definitive treatment to the time when acute phase has been controlled. The improved diagnostic techniques allow better preoperative planning and are useful in monitoring the response to treatment. Besides newer devices, cell-based treatments are promising tools which have recently enriched the treatment portfolio. However, the need for proctectomy is still disturbingly high in CD patients with complex perianal fistulae. CONCLUSIONS Perianal CD can impair quality of life and lead to need for proctectomy. A staged approach is reasonable. Treatment success can be improved by multimodal treatment and collaborative management by experienced gastroenterologists and surgeons.
Collapse
Affiliation(s)
- Gianluca Pellino
- Unit of General Surgery, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy
| | - Francesco Selvaggi
- Unit of General Surgery, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy
| |
Collapse
|
|
21
|
García-Granero A, Granero-Castro P, Frasson M, Flor-Lorente B, Carreño O, Garcia-Granero E. The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin. Colorectal Dis 2014; 16:O335-8. [PMID: 24853735 DOI: 10.1111/codi.12670] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 04/23/2014] [Indexed: 12/13/2022]
Abstract
AIM This technical note describes the use of an endostapler for the definitive treatment of supralevator abscess upward from an intersphincteric origin. METHOD A two-stage treatment was performed. First an endoanal drainage was performed by inserting a mushroom catheter in the supralevator abscess cavity. In the second stage transanal unroofing of the fistula was performed with an endostapler. RESULTS Since 2011, three patients have been treated in this way. After 2 years of follow up, none of the patients had recurrence of the abscess or been referred for anal incontinence. CONCLUSION The use of an endostapler in the treatment of supralevator abscess of intersphincteric origin may be an alternative to decrease the risk of recurrence and incontinence.
Collapse
Affiliation(s)
- A García-Granero
- Department of General Surgery, Hospital Arnau de Vilanova, Valencia, Spain
| | | | | | | | | | | |
Collapse
|
|
22
|
Sordo-Mejia R, Gaertner WB. Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease. World J Gastrointest Pathophysiol 2014; 5:239-51. [PMID: 25133026 PMCID: PMC4133523 DOI: 10.4291/wjgp.v5.i3.239] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 05/07/2014] [Accepted: 05/28/2014] [Indexed: 02/06/2023] Open
Abstract
Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.
Collapse
|
|
23
|
Crohn's disease—What the medical registrar and acute physician needs to know! J Acute Med 2013. [DOI: 10.1016/j.jacme.2013.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
|
24
|
Imaging techniques and combined medical and surgical treatment of perianal Crohn's disease. J Ultrasound 2013; 18:19-35. [PMID: 25767636 DOI: 10.1007/s40477-013-0042-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 10/05/2013] [Indexed: 12/13/2022] Open
Abstract
Crohn's disease is a chronic inflammatory disease which may involve any segment of the gastrointestinal tract, most frequently the terminal ileum, the large intestine, and the perianal region. The symptoms of perianal Crohn's disease include skin disorders, hemorrhoids, anal ulcers, anorectal stenosis, perianal abscesses and fistulas, rectovaginal fistulas and carcinoma of the perianal region. The perianal manifestations of Crohn's disease cause great discomfort to the patient and are among the most difficult aspects to treat. Management of perianal disease requires a combination of different imaging modalities and a close cooperation between gastroenterologists and dedicated surgeons.
Collapse
|
|
25
|
Gary MA, Wu J, Bradway M. The space between: a supralevator abscess caused by perforated diverticulitis. J Surg Case Rep 2013; 2013:rjt041. [PMID: 24964449 PMCID: PMC3813776 DOI: 10.1093/jscr/rjt041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Supralevator abscesses are the rarest manifestation of anorectal suppurative disease. We report a supralevator abscess in a 60-year-old male whose earliest presentation included poorly localized abdominal and pelvic pain, tenesmus, urinary retention and weight loss, initially treated as diverticular disease based upon imaging and presentation. Progressive symptoms led to the discovery of a pelvic abscess with subsequent percutaneous drainage, later followed by emergent laparotomy, where a single perforated diverticulum was revealed to be the source fistulization. He underwent a Hartmann procedure with concomitant drainage of supralevator and ischiorectal collections. Perirectal pain with neurological involvement is part of a constellation of signs and symptoms that should invoke a high index of clinical suspicion for supralevator abscess formation. Percutaneous attempts at drainage are often inadequate; definitive surgical therapy is the best approach to prevent recurrence and associated morbidity.
Collapse
Affiliation(s)
- Monique A Gary
- Department of Surgery, Berkshire Medical Center/University of Massachusetts Medical School, Pittsfield, MA, USA
| | - Jacqueline Wu
- Department of Surgery, Berkshire Medical Center/University of Massachusetts Medical School, Pittsfield, MA, USA
| | - Marcella Bradway
- Department of Surgery, Berkshire Medical Center/University of Massachusetts Medical School, Pittsfield, MA, USA
| |
Collapse
|
|
26
|
Causey MW, Nelson D, Johnson EK, Maykel J, Davis B, Rivadeneira DE, Champagne B, Steele SR. An NSQIP evaluation of practice patterns and outcomes following surgery for anorectal abscess and fistula in patients with and without Crohn's disease. Gastroenterol Rep (Oxf) 2013; 1:58-63. [PMID: 24759668 PMCID: PMC3941441 DOI: 10.1093/gastro/got001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Patients with Crohn’s disease (CD) are believed to have more aggressive anorectal abscess and fistula disease. We assessed the types of procedures performed and perioperative complications associated with the surgical management of anorectal abscess and fistula disease in patients with and without CD. Methods: The American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP, 2005-2010) was used to calculate 30-day outcomes using regression modeling, accounting for demographics, comorbidities and surgical procedures. ICD-9 codes for anorectal abscess or fistula were used for initial selection. Patients were then stratified, based on the presence or absence of underlying CD. Local procedures included incision and drainage of abscesses, fistulotomy and seton placement. Cutaneous fistulas were considered simple, while all others were classified as complex (-vaginal, -urethral and -vesical). Results: A total of 7,218 patients (mean age 45 years; 64% male) met inclusion criteria, with underlying CD in 345 (4.8%). CD patients were more likely to have a seton placed (9.9 vs 8.2%, P < 0.001) and be on steroids (15.4 vs 4.3%, P < 0.001). Thirty-seven percent of CD patients underwent local procedures, while 46% had a proctectomy and 8% underwent diversion. Fistulotomy was more common in those without underlying CD (16 vs 11%, P < 0.001). The overall complication rate after local treatment was 4.9%, with no difference between patients with and without CD (7.7 vs 4.9%, P = 0.144). This was not affected by fistula type—simple (7.9 vs 3.9%, P = 0.194) vs complex (33 vs 7.1%, P = 0.21)—or when stratified by wound (3.8 vs 2.4%; P = 0.26) or systemic complications (3.8 vs 2.5%; P = 0.53). Yet, complications following emergency procedures were higher in patients with CD (21.4 vs 5.9%, P = 0.047). Factors significantly associated with increased complications were Crohn’s disease (OR = 8.2), lack of functional independence (OR = 2.0), pre-operative weight loss (OR = 2.6) and pre-operative acute renal failure (OR = 5.6). Steroids were also associated with a 1.7-fold increase in complications, independent from CD. Conclusions: While most patients with anorectal abscess/fistula are treated with local procedures, proctectomy and diversion use is fairly common in those with underlying CD. Although complication rates following elective local procedures for anorectal abscess/fistula are similar in patients with and without CD, they are higher in patients on steroids and in CD patients undergoing emergent procedures.
Collapse
Affiliation(s)
- Marlin Wayne Causey
- Department of Surgery, Madigan Army Medical System, Madigan Health System, Tacoma, WA 98431, USA
| | | | | | | | | | | | | | | |
Collapse
|
|
27
|
Successful management of a recurrent supralevator abscess: a case report. Case Rep Surg 2012; 2012:871639. [PMID: 22649747 PMCID: PMC3357932 DOI: 10.1155/2012/871639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 12/26/2011] [Indexed: 11/17/2022] Open
Abstract
Anorectal abscesses are commonly encountered in clinical surgical practice. These abscesses require surgical management. Supralevator abscesses are thought to originate either from an ischiorectal or intersphincteric abscess extension or from an intraperitoneal source. These abscesses are quite uncommon and present a difficult surgical problem. We present a case here of a 42-year-old female with a recurrent supralevator abscess requiring multiple surgical procedures for adequate drainage and care of her abscess.
Collapse
|
|
28
|
Wise PE, Schwartz DA. The evaluation and treatment of Crohn perianal fistulae: EUA, EUS, MRI, and other imaging modalities. Gastroenterol Clin North Am 2012; 41:379-91. [PMID: 22500524 DOI: 10.1016/j.gtc.2012.01.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Perianal fistulizing disease is a common complication of CD that requires a multidisciplinary collaboration between gastroenterology, surgery, and radiology professionals for successful assessment and treatment. Optimal success comes from a combined medical and surgical approach to treat the fistulizing disease (see Fig. 1). Unfortunately, even with a variety of surgical options, a subset of patients require permanent fecal diversion and/or proctectomy to successfully treat their disease. Further studies (likely requiring large, multicenter trials) of novel medical and surgical treatments are still warranted to formulate optimal management of this complex condition.
Collapse
Affiliation(s)
- Paul E Wise
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Nashville, TN 37232-0252, USA
| | | |
Collapse
|
|
29
|
|
|
30
|
|
|
31
|
Viganò C, Losco A, Caprioli F, Basilisco G. Incidence and clinical outcomes of intersphincteric abscesses diagnosed by anal ultrasonography in patients with crohn's disease. Inflamm Bowel Dis 2011; 17:2102-8. [PMID: 21910171 DOI: 10.1002/ibd.21596] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 11/02/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intersphincteric abscesses have been reported as uncommon manifestations of perianal Crohn's disease (CD) in surgical series, and may be diagnosed earlier by means of anal ultrasonography. The aim of this study was to evaluate the incidence and outcomes of intersphincteric abscess in a prospective cohort of patients with CD referred for perianal symptoms. METHODS Of the 420 patients with CD attending our outpatient clinic over a period of 5 years, 55 (31 males, mean age 38 ± 13 years) underwent anal ultrasonography because of newly developed symptoms suggesting perianal disease; a clinical evaluation and perianal examination was performed on the same day. RESULTS An intersphincteric abscess was diagnosed in 23 (42%) of the 55 patients with perianal symptoms, for a total cumulative 5-year incidence of 5% (95% confidence interval [CI]: 3%-7%). During a median follow-up period of 23 months (range 6-53), four of these patients required surgery, four developed a perianal fistula or small ischiorectal abscess not requiring surgery, and 15 experienced a benign course. The patients with a benign course had a longer duration of CD at the time of onset of the perianal symptoms. CONCLUSIONS Intersphincteric abscesses frequently cause perianal symptoms in patients with CD, and their clinical outcomes vary from rapidly progressive inflammation to a benign self-limiting course. The favorable outcome observed in some patients supports a first-line conservative approach to the condition.
Collapse
Affiliation(s)
- Chiara Viganò
- Department of Medical Sciences, University of Milan, Milan, Italy
| | | | | | | |
Collapse
|
|
32
|
Liu CK, Liu CP, Leung CH, Sun FJ. Clinical and microbiological analysis of adult perianal abscess. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 44:204-8. [PMID: 21524615 DOI: 10.1016/j.jmii.2011.01.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 04/07/2010] [Accepted: 07/19/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND In Taiwan, Klebsiella pneumoniae is the predominant pathogen causing pyogenic liver abscess in patients with diabetes mellitus (DM). The purpose of our hospital-based study was to determine the predominant bacterial species causing perianal abscess in hospitalized patients with and without DM in Taiwan. METHODS Data on patients admitted and then operated on for perianal abscess during the period of March 2001 to December 2008 were reviewed. Information extracted from medical records included clinical information and laboratory data as well as culture and antibiotic sensitivity results. RESULTS A total of 183 patients underwent surgery for perianal abscess. The most common pathogen causing perianal abscess in non-DM patients was Escherichia coli (67.1%), and the most common pathogen isolated in DM patients was K pneumoniae (60%; p=0.009). Among the 25 patients with DM, incident DM was diagnosed in 24.0% (6 of 25). In addition, five patients had transient hyperglycemia. CONCLUSIONS Escherichia coli was the predominant pathogen isolated from perianal abscesses in patients without DM. Klebsiella pneumoniae, however, was the predominant pathogen isolated in DM patients. In both DM and non-DM patients, more than 90% of K pneumoniae isolates showed in vitro sensitivity to first-generation cephalosporins.
Collapse
Affiliation(s)
- Chien-Kuo Liu
- Division of Colon and Rectal Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | | | | | | |
Collapse
|
|
33
|
Roumeguère P, Bouchard D, Pigot F, Castinel A, Juguet F, Gaye D, Capdepont M, Zerbib F, Laharie D. Combined approach with infliximab, surgery, and methotrexate in severe fistulizing anoperineal Crohn's disease: results from a prospective study. Inflamm Bowel Dis 2011; 17:69-76. [PMID: 20623697 DOI: 10.1002/ibd.21405] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Infliximab is the only medical therapy that has been proven to be effective in fistulizing Crohn's disease (CD), but the recurrence rate of fistulas is high despite maintenance therapy. The aim of this prospective study was to evaluate the short- and long-term efficacy of a combined schedule with infliximab, methotrexate, and sphincter-sparing surgery in patients with severe fistulizing anoperineal CD. METHODS From January 2006 to November 2007, all consecutive patients in three referral centers with severe fistulizing anoperineal CD were prospectively included after primary drainage. At inclusion, patients received three infliximab infusions at weeks 0, 2, and 6, and maintenance therapy with methotrexate. A second optimized surgical step consisting of at least removal of setons was performed between the second and the third infliximab infusions. RESULTS Thirty-four CD patients (26 women; median age 38.5 years) with complex anoperineal fistula were enrolled (including 9 with recto-vaginal fistulas, and 10 with anorectal stenosis). At week 14 the response rate was 85% with 74% complete responders. At 1 year, 50% were still responders; luminal CD worsening was the major cause of relapse. Median Perineal Disease Activity Index (PDAI) and magnetic resonance imaging (MRI) scores significantly decreased from baseline to week 50. CONCLUSIONS A combined approach with infliximab induction, two surgical sphincter-sparing steps and methotrexate is effective in achieving short-term response in severe fistulizing anoperineal CD. The best maintenance regimen remains to be determined.
Collapse
Affiliation(s)
- Pauline Roumeguère
- CHU de Bordeaux, Hôpital Haut-Lévêque, Service d'Hépato-gastroentérologie, Pessac, France
| | | | | | | | | | | | | | | | | |
Collapse
|
|
34
|
Torkzad MR, Karlbom U. MRI for assessment of anal fistula. Insights Imaging 2010; 1:62-71. [PMID: 22347906 PMCID: PMC3259332 DOI: 10.1007/s13244-010-0022-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 04/16/2010] [Accepted: 04/28/2010] [Indexed: 12/14/2022] Open
Abstract
Magnetic resonance imaging (MRI) is the best imaging modality for preoperative assessment of patients with anal fistula. MRI helps to accurately demonstrate disease extension and predict prognosis. This in turn helps make therapy decisions and monitor therapy. The pertinent anatomy, fistula classification and MRI findings will be discussed.
Collapse
Affiliation(s)
- Michael R. Torkzad
- Department of Radiology, Uppsala University Hospital, 751 85 Uppsala, Sweden
- Department of Oncology, Radiology and Clinical Immunology Section of Radiology, Uppsala University, 751 85 Uppsala, Sweden
| | - Urban Karlbom
- Department of surgery, Uppsala University Hospital, Uppsala, Sweden
| |
Collapse
|
|
35
|
Cellini C, Safar B, Fleshman J. Surgical management of pyogenic complications of Crohn's disease. Inflamm Bowel Dis 2010; 16:512-7. [PMID: 20049952 DOI: 10.1002/ibd.20984] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Patients with Crohn's disease are prone to the development of pyogenic complications. These complications are most commonly in the form of perianal or intraabdominal abscesses and/or fistulas. Complications in these 2 distinct areas are managed differently; however, they are similar in the fact that initial treatment relies on medical or minimally invasive management to achieve a nonacute condition prior to definitive surgical procedure. This article reviews the current surgical management of obtaining pyogenic control in both anorectal and intraabdominal Crohn's disease.
Collapse
|
|
36
|
Abstract
Fistulas manifest frequently in Crohn disease and can result in significant morbidity and often lead to the need for surgical intervention. Historically, it has been more difficult to obtain complete fistula closure in patients with perianal Crohn disease. Anti-tumor necrosis factor-alpha agents and the use of more accurate imaging modalities such as magnetic resonance imaging and rectal endoscopic ultrasound have enhanced the ability to manage fistulizing Crohn disease. A combined medical and surgical approach usually presents the best option for most patients.
Collapse
Affiliation(s)
- David A Schwartz
- Division of Gastroenterology, Vanderbilt University Medical Center, Suite 514, 1211 21st Avenue, Nashville, TN 37232, USA.
| | | |
Collapse
|
|
37
|
Schwartz DA, Maltz BE. Treatment of fistulizing inflammatory bowel disease. Gastroenterol Clin North Am 2009; 38:595-610. [PMID: 19913204 DOI: 10.1016/j.gtc.2009.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Fistulas manifest frequently in Crohn disease and can result in significant morbidity and often lead to the need for surgical intervention. Historically, it has been more difficult to obtain complete fistula closure in patients with perianal Crohn disease. Anti-tumor necrosis factor-alpha agents and the use of more accurate imaging modalities such as magnetic resonance imaging and rectal endoscopic ultrasound have enhanced the ability to manage fistulizing Crohn disease. A combined medical and surgical approach usually presents the best option for most patients.
Collapse
Affiliation(s)
- David A Schwartz
- Division of Gastroenterology, Vanderbilt University Medical Center, Suite 514, 1211 21st Avenue, Nashville, TN 37232, USA.
| | | |
Collapse
|
|
38
|
Treatment of Perianal Crohn Disease Fistulae. PEDIATRIC INFLAMMATORY BOWEL DISEASE 2008. [PMCID: PMC7120280 DOI: 10.1007/978-0-387-73481-1_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
|
39
|
Abstract
Crohn's disease is commonly complicated by perianal manifestations. The surgeon plays a pivotal role in caring for these patients; a detailed history along with a thorough clinical exam provides the treating physician with invaluable information upon which to base further investigations and management decisions. Other than abscess drainage, medical management to control proximal disease often precedes any surgical attempt to cure the disease. Surgical interventions are indicated in selective patients, but are often complicated by poor wound healing and recurrences. A sizable percentage of these patients may need a proctectomy.
Collapse
Affiliation(s)
- Bashar Safar
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Dana Sands
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| |
Collapse
|
|
40
|
Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD. The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 2007; 9 Suppl 4:18-50. [PMID: 17880382 DOI: 10.1111/j.1463-1318.2007.01372.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- J G Williams
- McHale Centre, New Cross Hospital, Wolverhampton, UK.
| | | | | | | | | | | | | | | |
Collapse
|
|
41
|
Griggs L, Schwartz DA. Medical options for treating perianal Crohn's disease. Dig Liver Dis 2007; 39:979-87. [PMID: 17719859 DOI: 10.1016/j.dld.2007.07.156] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 02/06/2023]
Abstract
Perianal Crohn's disease can cause significant morbidity for patients affected by the disease. However, diagnostic modalities and treatment options have progressed changing the goals of treatment from fistula "improvement" to complete cessation of drainage. Fistula closure and fibrosis of the fistula track is achieved in some patients. Furthermore, treatment has become a combined effort between medical physicians and surgeons. Simple disease can be treated with medical therapy alone consisting of antibiotics and immunomodulators. Infliximab should be added to refractory simple disease or simple disease with the presence of inflammation. If complex fistula disease is evident a surgical evaluation should also be done to determine if intervention is indicated. Complex disease should be treated with antibiotics, immunomodulators and biologic therapy from the onset. This review will summarise current data regarding medical options for treatment of fistulising Crohn's disease.
Collapse
Affiliation(s)
- L Griggs
- Inflammatory Bowel Disease Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | | |
Collapse
|
|
42
|
Ingle SB, Loftus EV. The natural history of perianal Crohn's disease. Dig Liver Dis 2007; 39:963-9. [PMID: 17720635 DOI: 10.1016/j.dld.2007.07.154] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 12/11/2022]
Abstract
Perianal lesions are exceedingly common in Crohn's disease and many patients have more than one type of lesion. Skin tags, fissures and haemorrhoids may persist over time and are usually managed expectantly or with topical therapy. Perianal and rectovaginal fistulas and associated abscesses often require both local and systemic therapy, and recurrence is common. In general, the clinical course of Crohn's disease is more aggressive in patients with perianal involvement. Established risk factors for perianal disease include colonic disease and young age at disease onset. Classification schema now recognize perianal fistulas as distinct from other forms of penetrating Crohn's disease. Genetic susceptibility factors for perianal disease may exist, but they remain incompletely delineated at present. There is hope that immunosuppressive and biotechnology medications will influence the natural history of perianal disease by preventing invasive surgeries, disease complications and recurrence, but this needs to be confirmed. Cancer, a rare complication of perianal disease, must be suspected when lesions persist despite therapy.
Collapse
Affiliation(s)
- S B Ingle
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | | |
Collapse
|
|
43
|
Steele SR. Operative management of Crohn's disease of the colon including anorectal disease. Surg Clin North Am 2007; 87:611-31. [PMID: 17560415 DOI: 10.1016/j.suc.2007.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Evaluation and management of the patient who has Crohn's disease of the colon, rectum, and anus is challenging for even the most experienced provider. Because of its broad spectrum of presentation, recurrent nature, and potential for high morbidity, the surgeon needs to not only treat the acute situation but also keep in mind the potential long-term ramifications. Although there are exciting new medications and treatment modalities yielding promising results, surgery continues to remain at the forefront for the care of these patients. This article reviews various surgical options for the patient who has Crohn's disease of the colon, rectum, and perianal region with emphasis on symptomatic resolution and optimization of function.
Collapse
Affiliation(s)
- Scott R Steele
- Colon & Rectal Surgery, Department of Surgery, Madigan Army Medical Center, Fort Lewis, WA 98431, USA.
| |
Collapse
|
|
44
|
Abstract
Perianal Crohn's disease in children is a potentially debilitating condition that can precede or follow the intestinal disease component. The perianal abnormalities are varied and can include lesions of the perianal skin or anal canal, abscesses or fistulas, and malignancies. The appropriate management of these problems is predicated on a thorough evaluation of the perineum and anus as well as the remainder of the alimentary tract. Therapy usually includes a combination of antibiotics, immunomodulators, and biologic agents as well as conservative operative procedures. The surgical options are intended to safely ameliorate disease-related symptoms without compromising function or continence.
Collapse
Affiliation(s)
- Scott A Strong
- Departments of Colorectal Surgery and Pathobiology, Cleveland Clinic, Cleveland, Ohio 44195, USA.
| |
Collapse
|
|
45
|
Abstract
The management of patients with persistent perianal fistulae depends on thorough evaluation by clinical history and examination, assessment of intestinal disease and assessment of perianal disease. The main therapeutic options are medical and surgical treatment and their appropriate integration is essential for the optimal management of the patients. Medical treatment includes antibiotics, azathioprine or 6-mercaptopurine, infliximab and tacrolimus or cyclosporine. Surgical treatment includes fistulotomy, placement of setons, endorectal advancement flaps, fecal diversion and proctectomy. Fistula recurrence often occurs, possibly due to early discontinuation of medication or premature removal of setons. Using anorectal endoscopic ultrasound or magnetic resonance imaging to guide therapy, the healing rates of perianal fistula can be increased. In persistent complex perianal fistulae where medical treatment initially fails, examination under anaesthesia and placement of non-cutting setons, when necessary, combined with medical treatment results in higher healing rates.
Collapse
Affiliation(s)
- Ioannis E Koutroubakis
- Department of Gastroenterology University Hospital Heraklion, P.O. Box 1352, 71110 Heraklion, Crete, Greece.
| |
Collapse
|
|
46
|
Mardini HE, Schwartz DA. Treatment of perianal fistula and abscess: Crohn’s and non-Crohn’s. ACTA ACUST UNITED AC 2007; 10:211-20. [PMID: 17547859 DOI: 10.1007/s11938-007-0014-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The management of perianal abscesses and fistulas is relatively straightforward in most cases and based on a sound knowledge of the anatomy of the anorectum and adherence to established medical and surgical principles. Asymptomatic fistulas should not be treated, whereas abscesses require surgical drainage under general anesthesia. Fistula treatment includes drainage of any associated sepsis and eradication of the fistula track to prevent recurrence while preserving sphincter integrity. A small percentage of anal abscesses and fistulas are complex and very challenging to manage, particularly in conditions such as rectovaginal fistulas and abscesses and/or fistulas complicating Crohn's disease. Treatment strategies in these situations rely on an accurate clinical assessment of the degree of rectal inflammation and perianal pathology. Treatment should combine aggressive medical therapy (antibiotics, immunomodulators, and anti-tumor necrosis factor antibody treatment) and minimal surgical interventions. Patients with proctitis have a significantly lower healing rate and a significantly higher complication rate with aggressive surgical interventions.
Collapse
Affiliation(s)
- Houssam E Mardini
- David A. Schwartz, MD Director, Inflammatory Bowel Disease Center, Vanderbilt University Medical Center, 1501 TVC, Nashville, TN 37232, USA.
| | | |
Collapse
|
|
47
|
Mueller MH, Geis M, Glatzle J, Kasparek M, Meile T, Jehle EC, Kreis ME, Zittel TT. Risk of fecal diversion in complicated perianal Crohn's disease. J Gastrointest Surg 2007; 11:529-37. [PMID: 17436140 PMCID: PMC1852374 DOI: 10.1007/s11605-006-0029-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The purpose of the study was to determine the overall risk of a permanent stoma in patients with complicated perianal Crohn's disease, and to identify risk factors predicting stoma carriage. A total of 102 consecutive patients presented with the first manifestation of complicated perianal Crohn's disease in our outpatient department between 1992 and 1995. Ninety-seven patients (95%) could be followed up at a median of 16 years after first diagnosis of Crohn's disease. Patients were sent a standardized questionnaire and patient charts were reviewed with respect to the recurrence of perianal abscesses or fistulas and surgical treatment, including fecal diversion. Factors predictive of permanent stoma carriage were determined by univariate and multivariate analysis. Thirty of 97 patients (31%) with complicated perianal Crohn's disease eventually required a permanent stoma. The median time from first diagnosis of Crohn's disease to permanent fecal diversion was 8.5 years (range 0-23 years). Temporary fecal diversion became necessary in 51 of 97 patients (53%), but could be successfully removed in 24 of 51 patients (47%). Increased rates of permanent fecal diversion were observed in 54% of patients with complex perianal fistulas and in 54% of patients with rectovaginal fistulas, as well as in patients that had undergone subtotal colon resection (60%), left-sided colon resection (83%), or rectal resection (92%). An increased risk for permanent stoma carriage was identified by multivariate analysis for complex perianal fistulas (odds ratio [OR] 5; 95% confidence interval [CI] 2-18), temporary fecal diversion (OR 8; 95% CI 2-35), fecal incontinence (OR 21, 95% CI 3-165), or rectal resection (OR 30; 95% CI 3-179). Local drainage, setons, and temporary stoma for deep and complicated fistulas in Crohn's disease, followed by a rectal advancement flap, may result in closing of the stoma in 47% of the time. The risk of permanent fecal diversion was substantial in patients with complicated perianal Crohn's disease, with patients requiring a colorectal resection or suffering from fecal incontinence carrying a particularly high risk for permanent fecal diversion. In contrast, patients with perianal Crohn's disease who required surgery for small bowel disease or a segmental colon resection carried no risk of a permanent stoma.
Collapse
Affiliation(s)
- M H Mueller
- Department of Surgery, Ludwig-Maximilians-University, Marchioninistrasse 15, 83177, Munich, Grosshadern, and Department of General, Visceral and Transplantation Surgery, University Hospital, Tübingen, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
|
48
|
Abstract
Acute abdominal pain is a complaint seen commonly in the outpatient setting that has a broad and often confusing differential diagnosis. Although many presentations can be managed on an outpatient basis, several gastrointestinal causes of abdominal pain demand thoughtful consideration with subsequent referral to a higher level of care for appropriate diagnosis and treatment. To achieve this goal, outpatient physicians must have an understanding of the mechanisms of abdominal pain, as well as the common gastrointestinal causes that carry potentially higher morbidity and mortality.
Collapse
Affiliation(s)
- Mark H Flasar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland Medical Center, and Veterans Affairs, Maryland Health Care System, 10 North Greene Street, Baltimore, MD 21201, USA.
| | | | | |
Collapse
|
|
49
|
Abstract
The treatment of fistulizing CD has evolved greatly in the last 15 years, largely caused by improvements in medical therapy. Tables 2 and 3 summarize all published controlled and uncontrolled trials of immunomodulator and biologic therapy for the treatment of Crohn's fistulae. The advent of immunomodulators and anti-TNF-alpha agents has transformed the treatment of Crohn's fistulae from almost exclusively surgical to placing a much larger emphasis on medical therapy, either as initial therapy alone, with surgery reserved for refractory cases, or in combination with surgery from the start. For this reason, surgeons and gastroenterologists must work in concert to provide the best care for each patient. Proper fistula management also relies heavily on accurate diagnosis, especially defining the anatomy of the fistula, ascertaining whether abscess formation is present, and determining the location and extent of intestinal inflammation.
Collapse
Affiliation(s)
- Mark T Osterman
- Division of Gastroenterology, Department of Medicine, Penn Presbyterian Medical Center, University of Pennsylvania School of Medicine, 218 Wright Saunders Building, 39th and Market Streets, Philadelphia, PA 19104, USA
| | | |
Collapse
|
|
50
|
Lee H, Kim YH, Kim JH, Chang DK, Son HJ, Rhee PL, Kim JJ, Paik SW, Rhee JC. Nonsurgical treatment of abdominal or pelvic abscess in consecutive patients with Crohn's disease. Dig Liver Dis 2006; 38:659-64. [PMID: 16423568 DOI: 10.1016/j.dld.2005.12.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Revised: 11/29/2005] [Accepted: 12/01/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is little agreement about the efficacy of nonsurgical treatment for abscess associated with Crohn's disease. Furthermore, there is no study on characteristics of abscess or patient that nonsurgical treatment could be worth trying as initial treatment. AIMS To evaluate the outcome of nonsurgical treatment in Crohn's disease-related abscess and identify factor leading to failure of nonsurgical treatment of this complication. PATIENTS Twenty-four patients, who consecutively admitted for Crohn's disease-related abscess to our institution during a 7-year period, underwent nonsurgical treatment as initial therapy. METHODS Outcome data such as recurrence and intractability, and clinical features were retrospectively analysed. Univariate analysis with patient-related factors and abscess-related factors was performed for risk factor identification. RESULTS Median follow-up period was 47.5 months. Of the eligible patients, 19 patients were treated medically and 5 patients underwent percutaneous catheter drainage with medical treatment. Overall success rate of nonsurgical treatment in our centre was 66.7%. The cumulative recurrence rate at 7 months was 12.5%. All recurrences occurred within 7 months from complete resolution on follow-up imaging. Univariate analysis showed that the significant factors which lead to failure of nonsurgical treatment were presence of associated fistula and concurrent steroid use (P=0.019 and P=0.019, respectively). CONCLUSION Nonsurgical treatment can be considered as initial treatment modality for the Crohn's disease-related abscess without concurrent steroid therapy or relevant fistula.
Collapse
Affiliation(s)
- H Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-dong 50, Gangnam-Gu, Seoul 135-710, South Korea
| | | | | | | | | | | | | | | | | |
Collapse
|