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P222. Efficacy of different therapeutic options for spontaneous intraabdominal abscesses in Crohn's disease

F. Bermejo1, E. Garrido2, M. Chaparro3, J. Gordillo4, M. Mañosa5, A. Algaba1, A. López-Sanromán2, J.P. Gisbert3, E. Garcia Planella4, E. Domènech5, I. Guerra1

1Fuenlabrada Hospital, Fuenlabrada, Spain; 2Ramón y Cajal Hospital, Madrid, Spain; 3La Princesa Hospital, Madrid, Spain; 4Santa Creu i Sant Pau Hospital, Barcelona, Spain; 5Germans Trias i Pujol Hospital, Badalona, Spain

Aim: To assess the efficacy of different therapeutic options for spontaneous intraabdominal abscesses in Crohn's disease.

Methods: Retrospective study of cases diagnosed with intraabdominal abscesses in five university hospitals in the last fifteen years. Postoperative cases were specifically excluded. Therapeutic success was defined as the abscess non-reappearance within one year of follow-up.

Results: We identified 128 cases in 2236 patients (cumulative incidence 5.7%), 57% male. According to Crohn's location: 56.7% of cases were L1, 2.4% L2, 37% L3, 3.9% L1+L4. Presenting symptoms included abdominal pain (83%), fever (40%), and diarrhea (27%). Glucocorticoids were being administered at diagnosis in 35% of cases, immunosuppressants in 25%, biologicals in 5%. Abscesses were intraabdominal in 60% of cases, pelvic 24%, in psoas muscle 11%, and in the abdominal wall 5%. The anatomical region most frequently affected was the right lower abdomen (85%). Initial therapy included antibiotics alone (42.2%), antibiotics plus percutaneous drainage (23.4%) and antibiotics plus surgical drainage (34.4%). The preferred antibiotic regimens were the associations of a third-generation cephalosporin plus metronidazole (31%), ciprofloxacin plus metronidazole (26%), or carbapenem (19%). Glucocorticoids were indicated in 60% of cases. Median follow-up after initial therapy reached 50 months (interquartile range, IQR, 22–108). Abscess size averaged 4 cm (IQR 3–6). Abscesses treated with antibiotics alone were smaller (3 cm, IQR 2–4) than those treated with combined percutaneous (6 cm, IQR 3–9) or surgical approaches (5 cm, IQR 2–8). Abscesses were simple in 70% of instances, 25% multiples and 5% multiloculated. An intestinal fistula was evident in imaging techniques in 51% of cases. The final efficacy of the different approaches was as follows. Antibiotics alone: final efficacy 63%, immunomodulators at diagnosis (OR 8.45; 95CI% 1.16–61.5; p = 0.03), fistula detected in imaging techniques (OR 5.43; 95CI% 1.18–24.8; p = 0.02) and greater abscess size (OR 1.65; 95CI% 1.07–2.54; p = 0.02) were predictors of treatment failure; surgery eventually required in 37%. Antibiotics + percutaneous drainage: final efficacy 30%, complications 19% (13% enterocutaneous fistula); surgery eventually required in 70%; no predictors of treatment failure were found. Antibiotics plus surgery: final efficacy 91%, 5.7% required a definitive stoma and 95% an intestinal resection; in 52% a fistula was detected; 13% developed postoperative complications (7.7% enterocutaneous fistula). Following abscess resolution, 60% of patients were started on thiopurines, 9% with biologics and in 31% baseline therapy was not modified. The year of diagnosis did not influence these outcomes.

Conclusions: Management of spontaneous intraabdominal abscesses in Crohn's disease with antibiotics alone seems a good option for small abscesses without associated fistula and especially in immunosuppressor-naïve patients. Surgery offers better results in the remaining situations, although percutaneous drainage can avoid surgery in one third of patients.