Current management of spontaneous intra-abdominal abscess in Crohn's disease

Crohn's disease (CD) is a chronic transmural disease process with approximately 10% of patients developing spontaneous intra-abdominal abscess during the first 5 years after the diagnosis. The symptoms are often nonspecific. The treatment modalities include the use of wide-spectrum antibiotics, imaging-guided percutaneous drainage (PD) and surgical drainage with or without resection. The best initial treatment strategy has not been settled controversial, as there are only retrospective studies with small sample sizes available in the literature. The majority of the patients would eventually need surgery. However a highly selected patient population with small abscess in the absence of fistulas or bowel strictures, especially those naive to immunomodulators or biologics, may respond to medical treatment alone with wide-spectrum antibiotics. The increased use of PD drainage in the last few years has been shown to reduce postoperative morbidities and risk of fecal diversion, allowing for subsequent elective surgery. Varied success rates of PD drainage have been reported in the literature. The initial surgical intervention of CD-related spontaneous abdominal sepsis is mandatory in patients with diffuse peritonitis due to free perforation. Surgery is also indicated in those with failed initial medical treatment and/or PD. This review article was aimed to evaluate the treatment modalities for spontaneous intra-abdominal abscess in CD patients and propose an algorithm for the best management of this complication.