CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:842 850

EDUCATION PRACTICE
Current Strategies in the Management of Intra-abdominal Abscesses in
Crohns Disease
LINDA A. FEAGINS,* STEFAN D. HOLUBAR, SUNANDA V. KANE, and STUART J. SPECHLER*
*Divisions of Gastroenterology and Hepatology, VA North Texas Health Care System, and the University of Texas Southwestern Medical Center at Dallas, Dallas,
Texas; Department of Colorectal Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and Division of Gastroenterology and Hepatology,
Mayo Clinic, Rochester, Minnesota

Crohns disease is characterized by inflammation that involves the full thickness of the bowel wall, which can lead to
serious complications including intra-abdominal and pelvic abscesses. The combination of an intra-abdominal abscess with active Crohns disease poses a particular dilemma for the treating physician, who must weigh the
benefits of using immunosuppressive therapies for the inflammatory bowel disease against the risks of immunosuppression in the presence of serious abdominal infection.
Traditionally, Crohns-related abscesses were managed with
early surgery, which often involved external drainage procedures, bowel resection, and the creation of diverting ostomies in acutely ill patients. Today such abscesses often
can be managed initially with antibiotics and percutaneous
drainage, with evaluation for the need for delayed surgery in
selected patients. With delayed surgery performed electively,
the surgeon frequently can resect the diseased bowel and
create a primary anastomosis, thus avoiding emergency operations and multistage procedures. In highly selected cases,
surgery might be avoided entirely. This report reviews the
literature on the pathophysiology and management of intraabdominal abscesses in Crohns disease (including the roles of
percutaneous drainage, immunosuppressive therapy, and surgery), and provides a suggested approach to the management
of patients with this difficult problem.
Keywords: Crohns Disease; Abscess; Inflammatory Bowel Disease.

Clinical Scenario

33-year-old man with Crohns disease is referred for the

evaluation of abdominal pain in the right lower quadrant
associated with weight loss for the past month. He denies
fevers, chills, and night sweats. He continues to smoke cigarettes despite repeated medical advice to quit. Crohns disease
was first diagnosed 3 years earlier when he was found to have
inflammation of the distal ileum with an associated abscess,
which was treated with antibiotics and percutaneous aspiration.
Two years earlier, he was again found to have an abscess in the
area of the distal ileum. This time the abscess was treated with
antibiotics alone. After both episodes, he was advised to return
to the gastroenterology clinic for follow-up and to start immunosuppressive therapy on an outpatient basis; however he did
not return for the scheduled follow-up. He is in no acute
distress and his temperature is normal. Abdominal examination

reveals a tender mass in the right lower quadrant without

guarding or rebound tenderness. The remainder of the physical
examination is unremarkable. Laboratory tests reveal a normal
metabolic panel and a normal complete blood count. The
C-reactive protein level is 1.43 mg/dL and the erythrocyte sedimentation rate is 43. A computed tomography (CT) scan of the
abdomen reveals inflammation solely involving the distal ileum,
with a fistula from the diseased bowel to a 3.9-cm abscess cavity.
A restaging colonoscopy reveals that the terminal few centimeters of the ileum appears to be spared, and there is no evidence
of disease in the remainder of the colon.
What is the next best step in the management of this patient?

The Problem
Crohns disease is characterized by inflammation that
involves the full thickness of the bowel wall. Consequently, the
disease often is complicated by fistula formation, bowel perforations, and abscesses. Ten to twenty-eight percent of patients
with Crohns disease develop intra-abdominal or pelvic abscesses, which may be the diseases presenting feature, or which
may develop during the course of the illness either spontaneously or as a complication of surgery. The combination of an
intra-abdominal abscess with active Crohns disease poses a
particular dilemma for the treating physician who must weigh
the benefits of using immunosuppressive therapies for the inflammatory bowel disease against the risks of immunosuppression in the presence of serious abdominal infection. Traditionally,
intra-abdominal abscesses in Crohns disease were managed with
early surgery that often involved external drainage procedures,
bowel resection, and the creation of diverting ostomies in
acutely ill patients. Today, intra-abdominal abscesses frequently
are treated initially with antibiotics and percutaneous drainage,
with surgical resection of diseased bowel performed later, if
necessary, as an elective, 1-stage procedure. Nevertheless, the
physician treating patients who have Crohns disease compliAbbreviations used in this paper: ASCA, anti-Saccharomyces cerevisiae antibody; CT, computed tomography; CTE, computed tomography
enterography; MRE, magnetic resonance enterography; MRI, magnetic
resonance imaging; SBFT, small bowel follow-through; US, ultrasonography.
2011 by the AGA Institute
1542-3565/$36.00
doi:10.1016/j.cgh.2011.04.023

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ABSCESSES IN CROHNS DISEASE

843

Figure 1. Development, treatment, and treatment complication of a retroperitoneal (psoas) abscess in a patient with Crohns disease who did not respond
to medical therapy. (A) Retroperitoneal phlegmon (arrow), presumably the result of transmural bowel inflammation with fistulization and direct penetration
of bacteria from the diseased bowel. (B) Two weeks later, an abscess cavity is apparent (arrow), presumably the result of fibrin deposition encasing the
bacteria and inflammatory cells. (C) A retroperitoneal percutaneous drain has been inserted into the abscess cavity. (D) Bacterial contamination of the
subcutaneous tissues after surgical resection and drain removal resulted in a non-necrotizing, gas-forming soft tissue infection (double arrow).

cated by intra-abdominal abscesses confronts a complex array

of treatment options and difficult choices.

Mechanisms of Abscess Development

Patients with Crohns disease can develop intra-abdominal abscesses involving the peritoneum (including the pelvis),
the retroperitoneum (eg, psoas abscesses) and, less commonly,
the liver (Figure 1). Abscesses typically form in dependent
portions of the peritoneal cavity including the paracolic gutters,
the pelvis, the subdiaphragmatic (supra-hepatic) region, and in
between loops of bowel. The mechanisms underlying formation
of these abscesses include (1) transmural bowel inflammation
with fistulization and direct penetration of bacteria from the
diseased bowel to contiguous tissues, (2) remote (hematologic)
seeding of bacteria from the diseased bowel, and (3) peritoneal
contamination at the time of bowel surgery. In case series,
intra-abdominal abscesses in patients with Crohns disease have
been nearly equally divided between those that are spontaneous
and those that are postoperative. For spontaneous abscesses,

the most common location of the associated diseased bowel is

the ileocecal area. At least 80% of abscesses contain multiple
bacterial types, which are typically a mixture of aerobic and
anaerobic flora. The most common aerobes are Escherichia coli
and Enterococcus species, and the most common anaerobes are
Bacteroides fragilis and Peptostreptococcus species. Importantly,
fungal infections including Candida albicans may be present in
chronic abscesses, especially when patients are immune-suppressed, malnourished, or on protracted courses of antibiotic
therapy. The formation of an abscess involves a complex interaction between the bacteria and the host that results in
the accumulation of neutrophils in the infection along with the
deposition of fibrin that encases the area and entraps the
bacteria and inflammatory cells.

Risk Factors for Development of

Intra-abdominal Abscesses in Crohns Disease
Spontaneous intra-abdominal abscesses. A number of serologic and genetic markers have been associated with

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FEAGINS ET AL

the development of intra-abdominal abscesses in patients with

Crohns disease. For example, high serum titers of anti-Saccharomyces cerevisiae antibody (ASCA) have been associated with
internal-penetrating and fibrostenosing Crohns disease. Moreover, Crohns patients who are ASCA immunoglobulin Apositive or ASCA immunoglobulin Gpositive appear to be at increased risk for requiring surgical intervention early in the
course of their disease. Other serologic markers including Escherichia coli outer membrane-porin (OmpC), CBir1 flagellin
(CBir1), antilaminaribioside carbohydrate (Alca) and antichitobioside carbohydrate (Acca) also have been linked to internal penetrating disease, as have genetic markers including
polymorphisms of immunity-related guanosine triphosphatase family M (IRGM) and, possibly, the organic cation transporter (OCTN1/2) genes and disks large homolog 5 (DLG5)
gene. However, the clinical value of using these markers for
prognostic purposes in patients with Crohns disease has not
been established.
In addition to microbial characteristics and host genetics,
environmental factors also appear to contribute to abscess
formation in Crohns disease. Tobacco use has been associated
with higher rates of fistula and abscess development in several
studies of Crohns patients. In contrast, Agrawal et al found no
association between smoking and abscess formation, but did
find that Crohns patients treated with prednisone had a profoundly increased frequency of abscesses (odds ratio, 9.03). In
this same study, treatment with azathioprine had no apparent effect on the risk of intra-abdominal abscess or fistula
formation.
Postoperative intra-abdominal abscesses. As mentioned, intra-abdominal abscesses can develop as a complication of surgical therapy for Crohns disease from either anastomotic leakage or peritoneal contamination at the time of
operation. A number of studies have addressed the issue of
whether the use of immunosuppressive therapies in the perioperative period increases the risk of this complication. A study
from the Mayo Clinic that used multivariate adjustment for
steroid use found no increase in complications for Crohns
patients who were treated with infliximab or combination immunosuppressive therapy in the perioperative period. However,
there was a trend toward increased complications for patients
who received steroids preoperatively. A Belgian study also found
no significant increase in complications or postoperative length
of stay for patients treated preoperatively with infliximab, but
did note a trend toward increased early postoperative complications in those patients. Unfortunately, neither of these studies adjusted for disease severity, which also can influence the
rate of operative complications.
Appau et al performed a retrospective study of 60 Crohns
patients who had received infliximab within 3 months prior to
surgery, and compared them with a similar group of patients
who were not treated preoperatively with infliximab. Using
multivariate adjustment, the investigators found a significantly
higher risk for intra-abdominal abscesses in the group that
received preoperative infliximab (4.3% vs 10%, P .005). The
authors even recommended the use of a diverting stoma to
prevent abscess formation in such patients. However, it should
be noted that the infliximab group had significantly more
patients who also had been treated with steroids, which may
well have contributed to abscess formation. Kunitake et al
performed a similar study in patients with inflammatory bowel

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 10

disease (including 57 Crohns patients being treated with infliximab) who were equally matched regarding the preoperative
use of steroids. The investigators found no significant difference in the frequency of postoperative bowel leaks between the
infliximab-treated and untreated patients (3% vs 2.9%). Finally,
Alves et al found an increased frequency of postoperative septic
complications (odds ratio, 5.95) in 161 Crohns patients who
had been treated with steroids for more than 3 months before
ileocolonic resection. Taken together, these studies suggest that
the use of steroids increases the risk of intra-abdominal abscess
formation after surgery for Crohns disease, whereas the use of
infliximab has little, if any, impact on that risk in this patient
population.
Abscess diagnosis. An intra-abdominal abscess can
be suspected in patients with Crohns disease who have fever
and/or an abdominal mass. For detecting both spontaneous
and postoperative abscesses, CT and magnetic resonance imaging (MRI) are considered the most sensitive and specific imaging tests. Abdominal ultrasonography (US), with its lower cost
and lack of ionizing radiation, can be a reasonable diagnostic
test option as well. Using CT or MRI as a gold standard for
detecting abscesses, US has shown a mean sensitivity and specificity of 91.5% and 93%, respectively. The location of the abscess also influences the diagnostic accuracy of US. While US is
a highly sensitive test for the detection of superficial abscesses,
its sensitivity for detecting deep pelvic or retroperitoneal abscesses is substantially lower than that for CT and MRI. In a
study of 128 patients who had CT and US prior to surgery for
Crohns disease, the investigators compared the rate of intraabdominal abscess detection by those imaging tests. The sensitivity was 86% and 90%, respectively, and the specificity was 95%
and 85%, respectively, for CT and US.
Radiologic studies are important not only for the detection
of abscesses, but also for the identification of any associated
fistulas, a finding which can alter patient management. CT is
often the initial diagnostic test of choice for detecting intraabdominal abscesses. To identify the associated fistulas, however, enterography should be considered. Lee et al compared
magnetic resonance enterography (MRE), CT enterography
(CTE), and small bowel follow-through (SBFT) in 30 patients
with Crohns disease. They found that CTE or MRE were more
sensitive for detecting extraenteric complications, including fistulas, than SBFT (100% sensitivity for CTE or MRE, 50% for
SBFT). In a study of patients having surgery for Crohns disease,
preoperative CTE accurately predicted the presence of abscess
and fistula at surgery in 100% and 94% of patients, respectively.
In comparison, a study evaluating the performance of noncontrast enhanced MRI (ie, without the enterography protocol and
oral contrast) found that MRI had a sensitivity and specificity
of only 79% and 75%, respectively for the detection of intestinal
fistulas. An Italian study comparing MRE and CTE in patients
with Crohns disease found that MRE was superior to CTE for
the detection of fistulas.
For patients with spontaneous abscesses, when the acute
suppurative issues have been addressed, endoscopic assessment
of the bowel also should be considered to help guide the next
steps in patient management. Few data are available to guide
the decision regarding the optimal timing for performing
colonoscopy after treating an abscess; it is our practice generally
to wait 4 to 6 weeks. This colonoscopy allows for the precise
localization of the diseased bowel segments (in the colon and

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ABSCESSES IN CROHNS DISEASE

845

Figure 2. Suggested algorithm for management of intra-abdominal abscesses in patients with Crohns disease.

distal small bowel) and for the assessment of bowel disease

severity; this information is important for planning surgery and
for determining whether medical therapy for the inflammatory
bowel disease requires alteration.
When an intra-abdominal abscess is diagnosed in a patient
with Crohns disease, the clinician must address 2 key management issues: (1) does the abscess require drainage and, if so,
what is the best drainage procedure (percutaneous or surgical)?
(2) Should immunosuppressive therapy be continued, discontinued or started in patients with intra-abdominal or pelvic
septic complication (Figure 2)?

Management Strategies and Supporting

Evidence
Initial Management
The treatment of intra-abdominal abscesses in patients
with Crohns disease can be optimized by adopting an integrated,
multidisciplinary approach that involves coordination among gastroenterologists, colorectal surgeons, radiologists, and possibly,
infectious disease specialists. Once the diagnosis of an abscess
(spontaneous or postoperative) is made, antimicrobial therapy
should be initiated promptly using agents effective against enteric
gram-negative aerobic and facultative bacilli, enteric gram-positive
streptococci, and obligate anaerobic bacilli. Proposed antimicrobial
regimens that cover these organisms include ticarcillin-clavulanate, cefoxitin, ertapenem, moxifloxacin, or tigecycline used as
single agents, or a combination of metronidazole with cefazolin,
cefuroxime, ceftriaxone, cefotaxime, levofloxacin, or ciprofloxacin.
The duration of antibiotic treatment depends on the efficacy of
the chosen drainage procedure (see below). No study has addressed

specifically whether antibiotics should be administered parenterally or orally in this setting. We base our choice of antibiotic
delivery route (parenteral or oral) on the severity of the acute
infection. For an adequately drained abscess, antibiotics should be
continued for at least 3 to 7 days. If the abscess is not effectively
drained or if adequate clinical improvement is not seen within 3 to
5 days, a longer course of antibiotics is required, and reimaging
should be performed to ensure that no undrained fluid collections
remain.

Percutaneous Drainage
Over the last several decades, percutaneous drainage
(aspiration and insertion of a drainage catheter) for Crohnsrelated abscesses has emerged as a first-line treatment option
(Figure 1C), or as a temporizing measure for an acutely ill or
malnourished patient in preparation for future, elective surgery.
Initial small case series published in the late 1980s and 1990s
reported that Crohns-related intra-abdominal abscesses could
be successfully drained percutaneously in most cases, and that
surgery could be avoided entirely in some, but not all cases.
Subsequently, larger case series and retrospective studies of
patients with both spontaneous and postsurgical Crohns-related abscesses have shown that percutaneous drainage can be
performed successfully in 74% to 100% of cases, although 8% to
20% require more than 1 percutaneous drainage procedure. One
study found a 77% rate of technical success for a single drainage
procedure, with an 84% overall success after subsequent catheter manipulation or replacement. Moreover, with initial treatment by percutaneous drainage, early surgery was avoided in
14% to 85% of patients (Table 1). Unfortunately, the duration of
follow-up in these studies generally was short, and it is not clear

Not clear
0/48 (0%)
NA
Drainage of the abscess
allowing delayed elective
surgery
31/48
da Luz
Moreira
(2009)

Rypens (2007)

NA, not available.

aTechnical success of percutaneous drainage: completely drained abscess cavity.

None
48
22/48
29/48

8/15
3
12
10/14
8
14 (15)

48

253 mo
2/14 (14%)
15/15

1284 mo
75/83 (85%)
87/87

Success with 1 drainage and

no surgery in 30 days
No abscess at surgery
67/87
17
70
NA
11

16/32
13
19
19/32
10/20
32 (53)

Gervais
(2002)
Golfieri (2006)

Retrospective
review
Case series
Retrospective
review
Retrospective
review
Retrospective
review
Retrospective
review
Retrospective
review
Lambiase
(1988)
Safrit (1987)
Sahai (1997)

87

1.815 y
7/31 (23%)
30/32

23 y
0.551 mo
5/10 (50%)
15/27 (56%)
Not clear
20/27

No surgery
No surgery within 30 days
after catheter removal
No surgery within 60 days
5/10
15/27
1
7
8
20
NA
27/27
6/15
18

3/8
1
7
6/8
5

Case series
Casola (1987)

8 (9); 1 liver

Study type

10 (18); 3 (5) liver

24 (27)

23 y
3/8 (38%)
8/8

12/15 (80%)
15/15

Technical success of the

drainage
No surgery
15/15
4
11
5/15
7

Definition of success
Postoperative
Spontaneous
Steroid
use
Number of patients
(number of abscesses)

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 10

First author
(year)

15 (15); 1 liver

No surgery
needed
(long-term)
Technical
success of
percutaneous
drainagea
Successful
procedure
per study
criteria
Number
with
fistula
present

Table 1. Details of Studies Assessing Success of Percutaneous Abscess Drainage

NA

FEAGINS ET AL

Time of followup

846

how many of the patients in those series ultimately had surgery.

For patients with postoperative abscesses in particular, available
studies suggest that reoperation can be avoided with percutaneous drainage in 67% to 100% of cases (Table 2). In cases where
surgery is performed after percutaneous abscess drainage, furthermore, the surgeon often is able to perform a primary bowel
anastomosis and to avoid bowel diversion via ostomy construction, which often is required in primary surgical drainage procedures. Although pelvic abscesses once were considered less amenable to percutaneous drainage than abdominal abscesses, 1 study
found an 88% success rate for percutaneous drainage of postoperative pelvic abscesses and a 74% success rate for such drainage of
spontaneous pelvic abscesses. Using modern percutaneous drainage techniques, it appears that there is little difference in the
clinical outcome between abscesses in the pelvis and in the abdomen. With successful percutaneous drainage, defervescence and
clinical improvement typically occur within 24 to 48 hours, and
catheter output often decreases within 1 week.
The effect of abscess size on the success rate of percutaneous
drainage has not been evaluated specifically in any study. Nevertheless, it has been suggested that abscesses 3 cm in diameter are amenable to, and will not resolve without drainage,
while those 3 cm or less are likely to respond to antibiotics
alone or in combination with percutaneous aspiration (without
an indwelling catheter).
A number of studies suggest that percutaneous drainage of
Crohns-related abscesses is less successful when there are associated bowel fistulas. Sahai et al found that the need for surgery
within 30 days despite percutaneous drainage was significantly
higher for patients with associated bowel fistulas than for those
without (P .04). Golfieri et al found that among 70 patients
who had spontaneous pelvic abscesses treated with percutaneous drainage, all 11 failures were associated with a fistula to the
bowel. The presence of a fistula should be suspected when an
indwelling catheter in an abscess yields a persistently high
drainage output. For abscesses with indwelling catheters that
persistently drain 50 mL of fluid per day, some authorities
recommend a fistulogram or a contrast-enhanced MRI or CT
scan to seek an enteric fistula, even if a prior study had been
negative. Other factors associated with failure of percutaneous
drainage in 1 study included spontaneous abscesses (as opposed
to postsurgical) and first abscesses (as opposed to recurrent),
although these findings did not reach statistical significance
(P .09 in both cases).
Percutaneous drainage of intra-abdominal abscesses appears to
be a relatively safe procedure. No study has described serious
hemorrhage or organ damage due to catheter insertion. Several
studies have described enterocutaneous fistula formation at the
site of catheter placement in a minority of cases (Table 3). One
group attempted to minimize the formation of enterocutaneous
fistulas by withdrawing the catheters by only 1 to 2 cm per day
when drainage was complete. None of the 15 patients in that study
developed enterocutaneous fistulas. No other study mentions the
specific protocol for catheter withdrawal. Other reported complications included a few cases of fever or bacteremia that resolved
with medical treatment. In addition to enterocutaneous fistulas
and bacteremia, removal of percutaneous drainage catheters has
been associated with bacterial contamination of the subcutaneous tissues and the development of serious (eg, Clostridial, Streptococcal gas-forming) soft tissue infections, especially in the immune-suppressed patient (Figure 1D).

October 2011

ABSCESSES IN CROHNS DISEASE

847

Table 2. Spontaneous Versus Postoperative Abscesses With Initial Percutaneous Drainage

Study

Need for repeat surgery in

postoperative abscess

Need for surgical drainage in

spontaneous abscess

Surgery performed for diseased bowel after

successful drainage (no residual abscess)

Casola (1987)
Lambiase (1988)
Safrit (1987)
Sahai (1997)
Gervais (2002)
Golfieri (2006)
Rypens (2007)
Gutierrez (2006)

0/5 (0%)
0/1 (0%)
0/1 (0%)
1/7 (14%)
4/13 (31%)
2/17 (12%)
1/3 (33%)
NA

0/15 (0%)
5/7 (71%)
0/7 (0%)
6/20 (30%)
12/19 (63%)
11/70 (16%)
4/12 (33%)
4/29 (14%)

3/15 (20%)
0/7 (0%)
5/7 (71%)
5/20 (25%)
14/18 (78%)
NA
6/12 (50%)
5/29 (17%)

NA, not available.

Unfortunately, there are no randomized, controlled trials

comparing percutaneous and surgical drainage of Crohns-related abscesses. Gutierrez et al performed a retrospective study
comparing the outcomes of 37 patients who underwent percutaneous drainage as initial treatment for these abscesses with
the outcomes for 29 patients who had surgery as initial treatment. The investigators found that the time to resolution did
not differ significantly between the 2 treatment groups (25 days
vs 21.5 days, surgery vs percutaneous drainage, respectively, P
.08). After 1 year of follow-up, approximately 1-third of patients
treated with percutaneous drainage eventually had surgery.
Other studies have described variable rates of surgical intervention after percutaneous drainage, but long-term data generally
are lacking (see Table 1). All of these studies are limited by their
retrospective nature, their variable and typically short durations
of follow-up, and the disparate indications for surgery (ie,
surgery performed not because percutaneous drainage failed to
cure the abscesses, but because of a perceived need to remove
the diseased bowel that caused the abscesses).

Surgical Drainage
Surgical drainage of intra-abdominal abscesses due to
Crohns disease involves exploration of the abdomen and pelvis,
evacuation of all abscess contents, irrigation and debridement
of the abscess cavity (pulse-lavage suction irrigation), and, typically, en-bloc bowel resection with or without external (passive)
suction drainage. Although surgery may treat the acute septic
complication of Crohns disease, it is important to recognize
that surgery usually does not cure Crohns disease, as recurrence after bowel resection is the rule rather than the exception.
At 1 year after the surgical resection of diseased bowel for
patients with Crohns disease, endoscopic evidence of disease
recurrence can be found at the anastomosis in 73% to 93% of
cases, and clinical recurrence is seen in 20% to 30%. In addition,
bowel resection for Crohns disease can be complicated by

anastomotic septic complications and new fistula formation.

Today, surgical drainage of intra-abdominal abscesses is typically reserved for cases that are not amenable to or that have
failed percutaneous drainage, or for those that have failed to
resolve with maximal medical therapy.

Medical Management Alone

Few studies have addressed medical management alone
(without percutaneous or surgical drainage) as primary treatment for Crohns-related abscesses, and all available reports are
retrospective, observational studies. From the data that is available, there is a 37% to 50% rate of recurrence, and although
these studies suggest that some patients with Crohns-related
abscesses can respond to medical therapy without drainage, it is
not clear how to select patients for this therapeutic approach,
thus it is not recommended.

Adjuvant Immunosuppressive Use

Spontaneous abscesses. The use of immunosuppressive therapy (steroids, immunomodulators, biologic agents)
during the treatment of Crohns-related abscesses has not been
well studied, and few evidence-based data are available to guide
therapy. Felder et al reported a series of 24 patients with
Crohns disease and a palpable abdominal mass (phlegmon vs
abscess) who were treated with high-dose steroids. The mass
resolved entirely in 15 of the 24 patients and, in the other 9, its
size decreased by 50%. Fourteen patients subsequently required
surgery for persistent or recurrent symptoms, and were found
to have abscesses at the time of surgery. There were no apparent
complications resulting from the use of steroids in this setting.
The authors concluded that it was safe to treat Crohns patients
who have a palpable, abdominal mass with steroids. In the
aforementioned study by Sahai et al, all 27 patients who had
percutaneous drainage of their Crohns-related abscesses were
treated with concomitant intravenous antibiotics and steroids,

Table 3. Complications of Percutaneous Drainage

Study

Patients in study

Enterocutaneous fistulae

Infectious complications

Casola
Lambiase
Safrit
Sahai
Gervais
Golfieri
Rypens

15
8 (9 abscesses)
10 (18 abscesses)
24 (27 abscesses)
32
87
14 (16 abscesses)

None
None
None
3
1
None
1

1 (bacteremia)
None
1 (sepsis)
1 (fever)
None
None
None

848

FEAGINS ET AL

and 55% had resolution without surgery. In the remainder of

the previously described studies assessing outcome after medical, surgical, or percutaneous drainage of Crohns-related abscesses, patients were treated with antibiotics while continuing
the immunosuppressive therapy that they already were taking.
Many of the patients were taking steroids, a number were
taking 6-mercaptopurine or azathioprine, and a few were
treated with infliximab. None of the investigators described
reducing or stopping immunosuppression during treatment for
the abscesses. No study has addressed specifically the issue of
how to manage immunosuppressive therapy for patients who
have Crohns-related abscesses. However, if immunosuppressive
agents are going to be continued in the setting of intra-abdominal or pelvic sepsis, then it seems prudent to prescribe concomitant antibiotics, and to continue antibiotic therapy until
the septic source has been eradicated.
A post hoc analysis of the A Crohns Disease Clinical Trial
Evaluating Infliximab in a New Long-Term Treatment Regiman in
Patients With Fistulizing Crohns Disease (ACCENT) II study
explored how often Crohns patients with fistulizing disease who
are treated with infliximab develop abscesses. The study protocol
mandated that any abscess drainage must have occurred a minimum of 3 weeks prior to study entry. Although most of the study
patients had perianal fistulizing disease, there were 15 patients
with 22 abdominal-draining fistulas who were treated with infliximab, and none developed abscesses during the study period.
Based on these data and clinical experience, expert opinion holds
that immunosuppressive therapy can be started very soon after
successful percutaneous drainage of Crohns-related abscesses.
Postoperative abscesses. Recommendations for
starting immunosuppressive therapy for patients with postoperative abscesses differ from those for patients with spontaneous abscesses. For patients with spontaneous abscesses, immunosuppressive therapy is started as soon as possible after
percutaneous drainage based on the assumption that these
abscesses arose from diseased bowel, and that diseased bowel
requires treatment both to enable abscess healing and to prevent abscess recurrence. In contrast, postoperative abscesses
result from complications of surgery, and that surgery often
includes resection of the diseased bowel. In this setting, immediate immunosuppression is not required to prevent diseased
bowel from interfering with abscess healing, and early immunosuppression might impair abscess healing and predispose to
septic complications. Therefore, immunosuppressive therapy
generally is withheld from patients with postoperative abscesses
until those abscesses have healed. After abscess healing, immunosuppression can be started as indicated to prevent future
flares of inflammatory bowel disease (Figure 2).

Areas of Uncertainty
Primary Abscess Prevention
Ideally, Crohns-related abscesses should be prevented
rather than managed. This goal might be achieved if physicians
and surgeons work closely together in the management of
patients likely to develop such abscesses. Crohns patients at
especially high risk for abscess development include those with
a history of penetrating disease who are not responding well to
medical therapy. Moreover, a number of serologic and genetic
markers and environmental factors have been associated with
the development of intra-abdominal abscesses in patients with

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 10

Crohns disease. For patients with such markers and factors,

especially those whose disease is localized to a single segment of
bowel, early surgical resection may prevent the fistulization and
phlegmon formation that precedes abscess development (see
Figure 1). Unfortunately, the optimal timing of such surgery
remains more in the realm of medical art than of science.
Moreover, the clinical value of using biomarkers for prognostic
purposes in patients with Crohns disease has not been established. Further investigation into the prognostic and diagnostic
utility of such biomarkers coupled with investigation into potential strategies to reduce the risk of penetrating disease in
these higher risk individuals is needed. Moreover, further studies are needed to elaborate the specific criteria that can be used
as indications for surgical resection of the diseased bowel.

Abscess Management
Few high-quality studies are available on the management of either spontaneous or postoperative intra-abdominal
abscesses in patients with Crohns disease. There are no randomized, controlled trials comparing percutaneous, surgical,
and medical treatments. Reports on the management of
Crohns-related abscesses generally describe the results of retrospective, observational studies that are subject to numerous
biases. In patients with extensive bowel inflammation due to
Crohns disease, furthermore, it may be difficult to distinguish
a phlegmon (inflammatory mass) from an abscess (pus-filled
cavity), even with sophisticated imaging tests like CT and MRI.
This distinction has clinical importance, because an abscess
often is amenable to percutaneous drainage, whereas a phlegmon is not. Difficulties in distinguishing phlegmon from abscess can confound the interpretation of studies on the management of intra-abdominal abscesses in Crohns disease.
Although the presence of an associated fistula has been
reported to be a risk factor for the failure of percutaneous
drainage in Crohns-related abscesses, most studies on this issue
were conducted either before biologic therapies were available
or early in the era of biologic treatment. It is conceivable that
the early institution of biologic therapy after percutaneous
drainage of Crohns-related abscesses might result in fistula
closure and obviate surgical treatment. Further investigations
are needed to address this issue. Moreover, as described above,
no study has addressed specifically the issue of how to manage
immunosuppressive therapy for patients who have Crohnsrelated abscesses. Most reports have described the practice of
continuing patients on their current regimens of immunomodulators and/or steroids if those medications had been prescribed prior to abscess diagnosis. When starting immunosuppressive therapy de novo, it remains unclear how long a course
of antibiotics is needed or whether it is necessary to repeat
imaging to document resolution of the abscesses before beginning immunosuppression.
The data discussed above suggest that Crohns-related abscesses can be managed successfully without surgery in many
cases. However, these patients require close and meticulous
observation for signs of clinical deterioration, which herald the
need for further interventions. After the institution of percutaneous drainage and antibiotics for the treatment of Crohnsrelated abscesses, clinical improvement should be seen within 3
to 5 days, and drainage from any indwelling catheters should
decrease substantially within 1 week. If these criteria are not
met, or at the first sign of clinical deterioration, re-evaluation

October 2011

and reimaging are indicated to determine whether the abscess

has been adequately drained and, if not, whether further percutaneous manipulations or surgical treatments are required.
Few published data are available to guide the clinician in
deciding precisely when to remove or reposition an indwelling
catheter. As long as the indwelling catheter remains in place, it
is our practice to perform a non-CT sinogram (ie, injection of
radio-opaque contrast material into the fistula) at intervals of
every 1 to 2 weeks. The sinogram provides information on the
positioning of the catheter, the adequacy of abscess drainage,
and the size of the remaining abscess cavity. This information
is used to determine the need for further manipulation of the
catheter and whether the abscess cavity has diminished to the
point that the catheter can be removed.
For patients who have small abscesses that are treated with
antibiotics and aspiration, but without an indwelling catheter,
close clinical observation is required to ensure that further
intervention is not needed. At the first sign of clinical deterioration or if there is no clear clinical improvement within 3 to 5
days, reimaging is performed to reassess the need for intervention. If the patient does well, we usually repeat CT imaging to
document abscess healing after 4 to 6 weeks.
In the absence of definitive data, our suggested approach to
abscess management is outlined in Figure 2. However, prospective studies to delineate factors to determine which patients
would be best treated (ie, with the fewest complications, lowest
cost, and least time lost from work) with medical therapy alone,
medical therapy plus percutaneous drainage, or surgical therapy are sorely needed. Moreover, while management recommendations regarding the use of immunosuppressive therapies for
patients with abscesses can be gleaned from available reports,
prospective studies are needed to formulate optimal management strategies.

Published Guidelines
The most recent American College of Gastroenterology
practice guidelines (2009) on the management of Crohns disease in adults touch only briefly on the management of intraabdominal abscesses. Management with antibiotics, percutaneous, or surgical drainage followed by delayed intestinal
resection if necessary is recommended. However, the guidelines
also conclude that controlled data are lacking and they provide
no specific recommendations. Similarly, the most recent guidelines from the American Gastroenterological Association (2006)
state that surgery is an appropriate option for intra-abdominal
abscesses in patients with inflammatory bowel disease, but the
guidelines provide no specific management recommendations.

Recommendations
Our patient had an abscess cavity 3 cm in diameter
with an associated fistula. As outlined in Figure 2, our initial
management recommendations included antibiotics and percutaneous drainage of the abscess. The patient improved clinically
within 5 days, but catheter drainage persisted unabated. A
repeat CT scan revealed a persistent abscess and fistulous tract.
At that point, we recommended surgical resection of the diseased bowel. This decision was based on a number of factors
suggesting that nonsurgical management alone would not be
successful, including: (1) the presence of a fistula, (2) persistence of the abscess despite antibiotics and percutaneous drain-

ABSCESSES IN CROHNS DISEASE

849

age, (3) the history of previous abscesses in the same area, and
(4) the patients poor compliance with medical therapy. The CT
and colonoscopic evidence that the inflammatory disease was
confined to the distal ileum was another factor in favor of
surgical treatment. The surgeon resected a 15-cm segment of
distal ileum including the abscess, and fashioned an enteroenterostomy with preservation of the ileocecal valve. The patient
recovered quickly and felt well. Treatment with a biological
agent was recommended, but the patient declined this therapy.
Instead, he was started on azathioprine along with a 3-month
course of metronidazole. He has remained in clinical remission
in the 18 months since his surgery.
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Reprint requests
Address requests for reprints to: Linda A. Feagins, MD, Division of
Gastroenterology and Hepatology (111B1), Dallas VA Medical Center, 4500
South Lancaster Road, Dallas, Texas 75216. e-mail: linda.feagins@
va.gov; fax: (214) 857-1571.
Conicts of interest
The authors disclose the following: L.A. Feagins has grant support
from Centocor. S. Kane is a consultant for Abbott, Elan, UCB, Kyorin,
and Millenium, and has grant support from Elan, Shire, and Warner
Chilcott. The remaining authors disclose no conicts.
Funding
This work was supported by the Ofce of Medical Research,
Department of Veterans Affairs (Dallas, Texas; L.A. Feagins) and
the Harris Methodist Health Foundation, Dr Clark R. Gregg Fund
(L.A. Feagins).