Intra-abdominal collections in Crohn's disease: outcomes following anti-TNF therapy

Abstract

Background: Anti-tumour necrosis factor (TNF) agents have demonstrated efficacy in achieving remission, reducing hospitalisations and enhancing quality of life for patients with Crohn's disease. There are a number of studies addressing the risk of infection and post-operative complications of anti-TNF therapy. However, few studies have examined the outcome of intra-abdominal collections that develop before or during anti-TNF therapy. Our aim was to examine the clinical course of patients who developed intra-abdominal collections immediately before or during anti-TNF therapy.

Methods: We reviewed retrospectively the medical records of all CD patients attending Canberra Hospital between 2004 and 2015 who developed intra-abdominal collections and were treated with anti-TNF therapy. An intra-abdominal collection was defined as an abscess, collection or phlegmon seen on medical imaging with raised inflammatory markers. Perianal collections were excluded.

Results: A total of 13 CD patients developed intra-abdominal collections before or during anti-TNF therapy. The mean age was 32.8 years (SD =12.9) and 62% were females. Patients commenced anti-TNF therapy an average of 6.5 years (SD =7.2) from diagnosis of CD.

62% (8/13) received antibiotics and did not require surgery. Of these, two had evidence of micro-perforation that was managed with antibiotics; anti-TNF therapy was commenced subsequently with an effective outcome. Another two who had been on anti-TNF therapy, an average of 16 months, had radiological-guided drainage of an abscess. Of the other four patients who were treated successfully using antibiotics, two had commenced anti-TNF therapy an average of two months prior to developing intra-abdominal collections and another two were commenced on anti-TNF therapy two weeks after developing intra-abdominal collections.

Five patients (38%) underwent surgery. One each had a colo-enteric and a colo-cutaneous fistula, one had evidence of a perforation that needed urgent operative management, another had radiological drainage without success and one patient had initiation of anti-TNF therapy under antibiotic cover, but did not respond adequately and underwent surgery.

Conclusions: CD patients with intra-abdominal collections may be safely and effectively managed with a combination of antibiotics, percutaneous drainage and anti-TNF therapy. Surgery may not be necessary in the majority of cases. Further studies are needed to confirm these findings.