How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease...
-
Upload
merryl-randall -
Category
Documents
-
view
226 -
download
1
Transcript of How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease...
![Page 1: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/1.jpg)
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
![Page 2: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/2.jpg)
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
![Page 3: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/3.jpg)
Findings at Colonoscopy – Stricture in TI with Ulceration
![Page 4: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/4.jpg)
Should You Consider Escalation of Medical Treatment in this Case?
![Page 5: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/5.jpg)
Inflammatory vs. Fibrotic Stricture• Inflammation is present
– Mucosal hyperenhancement– Mesenteric fat stranding– Mesenteric hypervascularity (“comb sign”)
• Fibrosis is present– Abnormally thickened wall without signs of active
inflammation– “…dilation of the proximal intestine strongly
suggests a fixed, chronic obstruction”
Liu, YB, et al. Abdom Imaging 2006Kirsner’s Inflammatory Bowel Diseases 6th Edition 2004
![Page 6: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/6.jpg)
Pre-Stenotic Dilation is Associated with Increased Fibrosis and
Inflammation
No Dilation Dilation0
0.5
1
1.5
2
2.5
3
3.5
4
Fibrosis Inflammation
Adler, J. et al. Inflamm Bowel Dis 2012
![Page 7: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/7.jpg)
“Pure” Inflammatory and Fibrotic Strictures are Rare in Clinical Practice
Adler, J. et al. Inflamm Bowel Dis 2012
![Page 8: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/8.jpg)
Response to Medical Treatment for Complicated Crohn’s Disease
30 days 90 days 180 days0%
10%20%30%40%50%60%70%80%90%
100%
Complete Partial None
Days Since Initiation of Medical Therapy
Resp
onse
Rat
e
n= 11 17 24 13 15 19 10 8 10
Samimi, R., et al. 2010. Inflamm Bowel Dis
![Page 9: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/9.jpg)
Most Patients Require Surgery after Treatment for Complicated CD
Samimi, R., et al. 2010. Inflamm Bowel Dishttp://onlinelibrary.wiley.com/doi/10.1002/ibd.21160/full#fig2
Post operative complication rate 32% in patients exposed to anti-TNF
(years)
![Page 10: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/10.jpg)
Is There Any Downside in Attempting Medical Treatment for
Complicated Crohn’s Disease?
![Page 11: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/11.jpg)
Clinical Factors Predicting Postoperative Complications
• 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
![Page 12: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/12.jpg)
Does Pre-Operative Anti-TNF Use Increase the Risk of Postoperative
Complications?
![Page 13: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/13.jpg)
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
![Page 14: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/14.jpg)
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
![Page 15: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/15.jpg)
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
![Page 16: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/16.jpg)
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
![Page 17: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/17.jpg)
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
![Page 18: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/18.jpg)
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
![Page 19: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/19.jpg)
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
![Page 20: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/20.jpg)
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…..
![Page 21: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/21.jpg)
• Severe right-sided colitis
• Stricture at anastomosis
![Page 22: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/22.jpg)
CTE
![Page 23: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/23.jpg)
How do you manage this patient?
![Page 24: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/24.jpg)
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
![Page 25: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/25.jpg)
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
![Page 26: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/26.jpg)
• 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?
![Page 27: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/27.jpg)
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
![Page 28: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/28.jpg)
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)
![Page 29: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/29.jpg)
• Decisions to make at this point?–TPN vs. resuming diet–Early surgery (with diverting stoma)
vs. trial of medical treatment
![Page 30: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/30.jpg)
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
![Page 31: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/31.jpg)
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
![Page 32: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/32.jpg)
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
![Page 33: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/33.jpg)
• 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
![Page 34: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/34.jpg)
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.
![Page 35: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/35.jpg)
Source: Clinical Gastroenterology and Hepatology 2012; 10:400-404 (DOI:10.1016/j.cgh.2011.11.023 )
Copyright © 2012 AGA Institute Terms and Conditions
Cumulative Probability of Abscess Recurrence in Medically vs. Surgically Treated Patients
2/3 of patients had recurrence infirst 30 days
![Page 36: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/36.jpg)
Most Patients Require Surgery after Treatment for Complicated CD
Samimi, R., et al. 2010. Inflamm Bowel Dishttp://onlinelibrary.wiley.com/doi/10.1002/ibd.21160/full#fig2
Post operative complication rate 32% in patients exposed to anti-TNF
(years)
![Page 37: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/37.jpg)
Clinical Factors Predicting Postoperative Complications
• 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
![Page 38: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/38.jpg)
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
![Page 39: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/39.jpg)
Pros and Cons of Medical Treatment for Intraabdominal Abscess
• Pros:– Largest study from
Mayo Clinic shows equivalent outcomes compared to surgery
– May delay or prevent surgery
– Decrease length of stay
• Cons: – Use of anti-TNF may be
associated with increased post-op complications
– May delay inevitable– May “handicap” anti-
TNF agents as disease is at an irreversible stage
– Patients failing aggressive therapy unlikely to respond
![Page 40: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/40.jpg)
Recommendations• Initial treatment should be antibiotics and
percutaneous drainage• Consider bowel rest and nutritional support as
bridge to surgery especially if malnourished • Surgery should be recommended in patients with
– Medically refractory disease prior to IAA– Stricture associated with abscess
• Consider post-op anti-TNF in patients undergoing surgery
• In other patients, consider medical treatment after discussion of risks and benefits
![Page 41: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/41.jpg)
Extra Slides
![Page 42: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/42.jpg)
What is the natural history of CD after ileocolonic resection and
primary anastomosis?
![Page 43: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/43.jpg)
Natural History of CD After Surgery
1 2 3 4 5 6 7 80
102030405060708090
100
Survival without en-doscopic lesionsSurvival without symptomsSurvival without surgery
Years
Prob
abili
ty o
f Rec
urre
nce
Rutgeerts P, et al. Gastroenterology. 1990
![Page 44: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/44.jpg)
Rutgeert’s Endoscopic Score
i0
i4
i1
i3
i2
![Page 45: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/45.jpg)
Symptomatic Recurrence Based on Degree of Endoscopic Activity
0 1 2 3 4 5 6 7 80
0.2
0.4
0.6
0.8
1
1.2
i0+i1i2i3i4
Years
Prob
abili
ty o
f Rec
urre
nce
Rutgeerts P, et al. Gastroenterology. 1990
![Page 46: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/46.jpg)
How Do We Manage CD Patients After Surgery?
• Can we predict who is more likely to have recurrence?
• How should patients be followed?• When should colonoscopy be performed?• Which medications should be given?• How should endoscopic recurrence be
managed?
![Page 47: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/47.jpg)
Risk Factors Associated with Postoperative CD Recurrence
• Patient Related– Smoking – Younger age at diagnosis
• Disease-Related– Perforating > fibrostenotic– Disease duration < 10 years– Ileocolitis > ileitis > colitis– Disease refractory to medical therapy
• Surgery-Related– Ileocolonic anastomosis > ileal > ileostomy
Kirsner’s Inflammatory Bowel Diseases 6th edition 2004
![Page 48: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/48.jpg)
Postoperative Prevention RCTs Clinical Recurrence Endoscopic recurrence
Placebo 25% – 77% 53% - 79%
5 ASA 24% - 58% 63% - 66%
Budesonide 19% - 32% 52% - 57%
Nitroimidazole 7% - 8% 52% - 54%
AZA/6MP 34% – 50% 42 – 44%
Summary of Postop RCTs5-ASA, Nitroimidazoles, AZA/6-MP
Regueiro M. Inflamm Bowel Dis. 2009
![Page 49: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/49.jpg)
IFX Reduces Post-operative Recurrence after Intestinal Resection
Placebo IFX0
10
20
30
40
50
60
70
80
90
100
Endo
scop
ic R
ecur
renc
e Ra
te
Regueiro, M., et al. Gastroenterology. 2009
Endoscopic Recurrence: endoscopic scores of i2, i3, or i4
![Page 50: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/50.jpg)
Why not wait until after disease has recurred endoscopically to
start treatment?
![Page 51: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/51.jpg)
Rates of Mucosal Healing are Decreased with Delays in Starting
Treatment
Series10
20
40
60
80
100
120SorrentinoRegueiroYoshidaFernandez-BlancoMantzarisYamamotoRegueiro2Mantzaris2Sorrentino2SONICACCENT 1MUSICEXTEND
Prop
ortio
n of
Pati
ents
with
M
ucos
al H
ealin
g
![Page 52: How to Assess and Manage Strictures, Abscesses, and Phlegmons in the Complicated Crohn’s Disease Patient David A Schwartz, MD Associate Professor of Medicine.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649ce45503460f949b1787/html5/thumbnails/52.jpg)
Risk of Post-Op Recurrence
LowLow ModerateModerate HighHigh
No MedsNo Meds
Colonoscopy 6-12 months post-op
Colonoscopy 6-12 months post-op
No Recurrence
No Recurrence
6MP or AZA ± metronidazole
6MP or AZA ± metronidazole
Anti-TNFAnti-TNF
Colonoscopy 6-12 months post-op
Colonoscopy 6-12 months post-op
No Recurrence
No Recurrence
Colonoscopy every 1-3 yrs
Colonoscopy every 1-3 yrs
Immunomodulator or anti-TNF
Immunomodulator or anti-TNF
Colonoscopy every 1-3 yrs
Colonoscopy every 1-3 yrs
anti-TNF or Δ biologics
anti-TNF or Δ biologics
Recurrence Recurrence
Long-standing CD, 1st surgery, Stricture <10 cm<10yrs CD, Stricture >=10 cm or inflammatory CDPenetrating disease, > 2 surgeries
Regueiro, M. Inflamm Bowel Dis. 2009