P547 Phlegmonous Crohn's disease: A review of outcomes at a tertiary centre
K.V. Patel*1, C.I. Amadi1, S. Fong1, I. Nasr1, N. Griffin2, E. Westcott3, A.B. Williams3, A.A. Darakhshan3, S.H. Anderson1, P.M. Irving1, J.D. Sanderson1
1Guy's and St Thomas' NHS Foundation Trust, Gastroenterology, London, United Kingdom, 2Guy's and St Thomas' NHS Foundation Trust, Radiology, London, United Kingdom, 3Guy's and St Thomas' NHS Foundation Trust, Colorectal Surgery, London, United Kingdom
Penetrating Crohn's disease (CD) can be complicated by sealed-off perforation resulting in the development of an phlegmon (inflammatory mass). The optimal management strategy and long-term outcomes of phlegmons in CD remains unknown.
Patients with CD and confirmed phlegmons on MRI/CT between January 2009 and December 2013 were identified retrospectively. Radiographic evidence of co-existing strictures, abscess, fistula and/or perforation was recorded. Medical records were reviewed and demographic data, CD phenotype, CD therapy prior to and following presentation, requirement for abscess drainage or surgical resection, and clinical status at most recent follow-up were recorded. Clinical remission was defined as a Harvey -Bradshaw index of <5. Repeat imaging was evaluated to assess phlegmon resolution.
17 patients (8 male) were identified with median follow up of 40 months (range 33-61 months). 4 had ileal and 13 had ileocolonic CD. 13 had co-existing strictures, 6 had co-existing abscess, and 5 had co-existing enteroenteric fistula. 6 patients were receiving a thiopurine at presentation with phlegmon. 16 patients reported significant abdominal pain with 9 requiring admission. In 5 of these, imaging studies confirmed perforation. 2 patients required short-term parenteral nutrition and 6 were managed with exclusive liquid diet.
8 patients were treated primarily with medical management (2 with prolonged courses of antibiotics, 6 with thiopurine and corticosteroids, and subsequently 3 escalated to an anti-TNF agent) and this led to phlegmon resolution in 5 patients, and clinical remission in 3 patients. 3 patients have subsequently required surgery, and 1 persists with low grade obstructive symptoms treated conservatively.
9 patients were managed with primary surgery. All received a thiopurine as post-operative prophylaxis, of whom 4 escalated to an anti-TNF agent for significant post-operative recurrence. Repeat surgical resection or abscess drainage was not required subsequently.
3 of 5 patients presenting with perforation and phlegmon at presentation were treated surgically, 2 of 5 patients with enteroenteric fistula and phlegmon at presentation were treated surgically, and 4 of 6 patients with abscess and phlegmon at presentation were treated surgically. All 6 patients on thiopurine at presentation required surgery.
Phlegmonous disease remains challenging to treat. Medical and surgical management are both viable options, however phlegmon resolution was more likely in the surgically treated group. Medically treated patients remain at risk of need for future surgery. Surgically treated patients require aggressive medical treatment post-operatively, to limit recurrence of CD.