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FIGURE 2
Magnetic resonance imaging of the abdomen and pelvis revealing the postoperative appearance of the exploratory laparotomy with significant interval decrease in size of the large intra-abdominal abscess. Small pockets of fluid still identified (asterisks).
No evidence of bowel perforation detected.
cavity. Common locations include abdominal wall (40 percent), peritoneal cavity (29 percent), retroperitoneum (26 percent), and sub-phrenic region (6 percent).3 Clinical presentation can be variable, but abdominal pain, fever, palpable abdominal mass, 4 Delayed presentation and diagnosis is common, as was evident in the patient we presented above.
The relationship of tumor necrosis factor alpha (TNF-alpha) immunomodulatory therapy on serious infection risk, and by extension abscess formation, is controversial. In a Mayo clinical infection event, half of which were felt to be serious.5 Rate of intraabdominal abscess formation is estimated to be 2.5 percent with adalimumab therapy, accounting for the majority of all serious infectious complications.6 Recent analysis of the TREAT registry also showed an increased risk for serious infections with TNF- alpha therapy in Crohn’s disease on unadjusted analysis, however multivariate analysis suggested that TNF-alpha therapy was not
an independent risk factor for serious infection (OR 0.99), unlike steroid use (OR 2.21), narcotic use (OR 2.38) and moderate-to severe disease activity (OR 2.11). Management of intraabdominal abscesses in Crohn’s disease has traditionally focused on early external surgical drainage, bowel resection, and creation of
diverting ostomies. However, increasingly smaller abscesses are being managed with antibiotics and percutaneous drainage, followed by delayed surgical resection of diseased bowel.7
Although abscess formation in Crohn’s disease is a fairly common occurrence, the presence of a massive intra-abdominal purulent the literature. It is interesting to note the development of the abscess on prednisone and adalimumab therapy, both of which have been to various degrees implicated in the development of serious infections in Crohn’s disease patients. Furthermore, despite the abscess taking up most of the abdominal cavity, the fairly limited symptom burden highlights the importance of having high degree of clinical suspicion for infectious complications in Crohn’s disease patients even when classical symptoms are not present.
CONTRIBUTING AUTHORS
■ EMILY AU is a student at Saint Louis University School of Medicine in St. Louis, Mo.
■ AHMAD AL-TAEE, MD is an Internal Medicine Resident at the Saint Louis University Hospital in St. Louis, Mo.
■ MUHAMMAD B. HAMMAMI, MD is a Gastroenterolgy and Hepatology Fellow at Saint Louis University Hospital in St. Louis, Mo.
REFERENCES
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3. Yamaguchi A, Matsui T, Sakurai T, et al. The clinical characteristics and outcome of intraabdominal abscess in Crohn’s disease.
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4. Georgopoulos F, Mylonaki, M, Malgarinos, G, et al. Intraabdominal abscesses in patients with Crohn’s disease: clinical data and therapeutic manipulations in 17 cases of a single hospital setting. Ann Gastroenterology. 2008;21:188–192.
5. Colombel JF, Loftus EV Jr., Tremaine WJ, et al. The safety profile of infliximab in patients with Crohn’s disease: the Mayo clinic experience in 500 patients. Gastroenterology. 2004;126:19-31.
6. Colombel JF, Sandborn WJ, Panaccione R, et al. Adalimumab safety in global clinical trials of patients with Crohn’s disease. Inflamm Bowel Dis. 2009;15:1308-1319.
7. Feagins LA, Holubar SD, Kane SV, Spechler SJ. Current strategies in the management of intra-abdominal abscesses in Crohn’s disease.
Clin Gastroenterol Hepatol. 2011;9:842-850.
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Del Med J | September 2016 | Vol. 88 | No. 9
