How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine Director, IBD Center Vanderbilt University Raymond Cross, MD, MS Associate Professor of Medicine Director, IBD Program University of Maryland School of Medicine
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How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.
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How to Assess and Manage Strictures, Abscesses, and Phlegmons in the
Complicated Crohn’s Disease Patient
David A Schwartz, MDAssociate Professor of Medicine
Director, IBD CenterVanderbilt University
Raymond Cross, MD, MSAssociate Professor of Medicine
Director, IBD ProgramUniversity of Maryland School of
Medicine
Case Presentation #1
• 17 year old woman with obstructing ileal CD with upper tract involvement has been hospitalized twice for treatment of partial SBO
• Treated with oral 5-ASA and three courses of steroids
• Imaging demonstrates 5 cm stricture with wall enhancement, mesenteric adenopathy and proximal dilation
Findings at Colonoscopy – Stricture in TI with Ulceration
Should You Consider Escalation of Medical Treatment in this Case?
Inflammatory vs. Fibrotic Stricture• Inflammation is present
• CD patients operated on between 1980-1997 (n=343)– 566 operations and 1,008 anastomoses– Intraabdominal septic complication in 13%– Predictors
• Low albumin (<3.0 g/dl)• Preoperative steroids• Abscess at laparotomy• Fistula at laparotomy
– If all 4 present, risk 50%!– If 0 factors present, risk 5%
Yamamoto, T et al. Dis Colon Rectum 2000
Does Pre-Operative Anti-TNF Use Increase the Risk of Postoperative
Complications?
Author Year Type of Procedure
# of Patients/# exposed to Anti TNF
Findings
Tay, GS 2003 Resection or plasty
100/14 ↓ complications
Marchal 2004 Resection 79/40 No effect
Colombel 2004 Resection, plasty or bypass
270/52 No effect
Kunitake 2008 Abdominal surgery
413/101 No effect
Appau 2008 Resection 389/60 ↑ complications
Nasir 2010 Surgery with “suture or staple line”
377/119 No effect
Canedo 2011 Resection 225/65 No effect
El-Hussuna 2012 Resection 417/32 No effect
Waterman 2012 Abdominal surgery
473/195 ↑ complications
Krane 2013 Resection 518/142 No effect
Risk Associated with Anti-TNF in CD Patients Undergoing Surgery
• 325 surgeries in 211 CD patients at UMB between 2004-2011• All abdominal surgeries were included
• At least one resection (n=211)• Diverting stoma (n=117)• Emergent (n=39)
• 150 had anti-TNF ≤ 8 weeks before surgery• 97% were within standard maintenance intervals
• 43% of biologic patients with perianal disease compared to 27% of controls
Syed, A., et al. Am J Gastroenterol 2013
Adverse Postoperative Outcomes• All complications were defined as those within 30
days from the date of surgery or discharge• Intra-abdominal septic complication: abdomino-
pelvic abscess, peritonitis, or anastomotic leak • Surgical site complication: intra-abdominal septic
complication, wound dehiscence, local fistula, or wound infection
• Infectious complication: any wound infection, abdomino-pelvic abscess, peritonitis, sepsis, pneumonia, or other major infection
Syed, A., et al. Am J Gastroenterol 2013
Anti-TNF Use is Associated with an Increased Risk of Complications
Outcome Anti-TNF vs. no anti-TNF OR (95% CI)
IASC 2.01 (0.85-4.74)
Surgical site complications 1.96 (1.02-3.77)
All infectious complications 2.43 (1.18-5.03)
Any major complication 1.85 (0.89-3.83)
Syed, A., et al. Am J Gastroenterol 2013
Anti-TNF are Associated with an Increased Risk of Complications in CD
• Meta-analysis (n=4,659 patients)– 18 studies
• Patients with CD using pre-op anti-TNF had an increase in:– Postop infectious complications (OR 1.93)– Total complications (OR 2.19)
• UC patients using pre-op anti-TNF did not have increased risk of complications
Narula, N et al. Aliment Pharmacol Ther 2013
Steps to Decrease Postoperative Complications in CD
1. Treat septic complications2. Improve nutrition3. Decrease or eliminate corticosteroids4. Do not start anti-TNF or hold dose(s) if
surgery is imminent
Both you and the patient agree to pursue surgery instead of medical therapy
1. Proximal dilation suggests more severe fibrosis2. Medical therapy unlikely to result in durable response 3. Anti-TNF therapy is associated with postoperative complications4. Stricture is short
45 yo Male with Intra-Abdominal Abscess
• 45 yo male presents with history ileocolic resection 10 years before. No maintenance medication post-op.
• Presents now with 3 month history of abdominal pain after eating. 20# wt loss during this time.
• FH: positive for Crohn’s• PE: Some RLQ tenderness and possible
fullness…• Colonoscopy and Imaging show…..
• Severe right-sided colitis
• Stricture at anastomosis
CTE
How do you manage this patient?
Long-Term Course of Crohn’s Disease
N = 2002 patients with Crohn’s disease since diagnosis of the disease Cosnes J et al. Inflamm Bowel Dis. 2002;8:244–250.
Cu
mu
lati
ve p
rob
abil
ity
(%)
Months
Probability of remaining free of complications
0 24 48 72 96 120 168 192 216 240144
100
90
80
70
60
50
40
30
20
10
0
Penetrating
Stricturing
How Do You Evaluate and Treat a Patient with an Intraabominal Abscess?
• Cross sectional imaging with positive oral contrast
• Intravenous antibiotics with coverage against gram – and anaerobic bacteria
• Drainage– Percutaneous if possible– Open if septic and/or abscess
not amenable to perc drainage• Avoid steroids!
– Reduce dose if possible• Hold immune suppressants
and biologics in short term• Nutritional Support
– Bowel rest initially– TPN
How Do You Evaluate and Treat a Patient with an Intraabominal Abscess?
Initial Management
• Abscess needs to be drained especially if > 3 cm. (poor penetration of antibiotics)– Perc drainage
successful in 77% of the time in largest study. 1
1-Golfieri et al. Tech Coloproct 2006
Drainage is achieved…. Now what?
• Continue antibiotics• Wait for patient to be afebrile for 48-72 hours
and re-image• If wbc remains elevated and /or fever persists
re-interrogate the drain• Consider scope (if one has not been done
recently to help guide treatment)
• Decisions to make at this point?–TPN vs. resuming diet–Early surgery (with diverting stoma)
vs. trial of medical treatment
TPN vs. Diet
• Retrospective report of the use of short-term TPN in pts with penetrating disease– 78 pts given pre-op nutritional treatment (median
23 days) and weaned off steroids, immunosuppressives1
• Need for stoma was only 8% • major complications 5%
1- Zerbib, APT 2010
Perioperative TPN in Surgical Patients
• Malnourished Veterans undergoing laparotomy or noncardiac thoracotomy (n=395)
• TPN group received TPN for 7-15 days prior to surgery and 3 days after
• Severely malnourished Veterans who received TPN– Fewer infectious complications than controls (5 vs.
43%, p=0.03)
The Veterans Total Parenteral Nutrition Cooperative Study Group N Engl J Med 1991
Early Surgery vs. Attempt at Medical Treatment
• 1st determine if abscess related to stricture /fistula and if stricture is fibrotic vs. inflammatory
• If stricture is present (especially if fibrotic) treatment is largely surgical• No prospective trial to look specifically at internal fistulas.
– In general, internal fistulas less likely to respond to anti-TNF treatment.
External Internal0
20406080 69
13
Response Rate to IFX
Response Rate%
Parsi, Am J Gastro 2004
• In general, if fistula present chance of non-surgical success is low– Sahai et al. found in retrospective study of 27 pts
with intra-abd abscess that associated fistulas was associated with need for surgery within 30 days despite drainage1
– Golfieri et al. found in a study of 70 patients that all failures of perc drainage were associated with a fistula to the bowel 2
Early Surgery vs. Attempt at Medical Treatment
1-Sahai et al. Am J Gastro 19972-Golfieri et al. Tech Coloproct 2006
Medical vs. Surgical Treatment of IAA
• Retrospective review of 95 patients from Mayo Clinic (1999-2006)
• 55 underwent percutaneous drainage (PD)– More likely female, older, longer disease duration, and active
ileal disease– 12 (22%) underwent PD as an outpatient
• 9/40 (23%) had high severity of illness and 9/40 (23%) had multiple abscesses in surgical group
• Median follow up 3.5 years• Perianal disease and active ileal disease positively and
anti-TNF negatively associated with recurrenceNguyen, D. L. et al. (2012). Clin Gastroenterol Hepatol.
Source: Clinical Gastroenterology and Hepatology 2012; 10:400-404 (DOI:10.1016/j.cgh.2011.11.023 )