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Background: Intra-abdominal collections in the form of abscesses or matted bowel loops, called phlegmons, might occur in patients with Crohn's disease (CD). The clinical characteristics and management of such conditions are not well described. We aim to characterize CD-related intra-abdominal collections clinically, and identify predictors of need for surgical interventions and the time to surgery. Methods: We utilized the Saudi Inflammatory Bowel Disease Information System (IBDIS) database to identify all patients treated for radiologically proven intra-abdominal abscesses or phlegmons since inception. Demographics, clinical data, clinical course, and treatment outcomes were recorded. Logistic regression analysis and survival analysis were used to identify predictors of surgical resection and differences in time to surgery between patient subgroups, respectively. Results: A total of 734 patients with a diagnosis of CD were screened and 75 patients were identified. The mean age was 25.6 ± 9.9 years and 51% were males. Nearly 60% of patients had abscesses larger than 3 cm while 13% had smaller abscesses and 36% had phlegmons. On presentation, the most commonly reported symptom was abdominal pain (99%) followed by weight loss (27%). About 89% of patients were treated with antibiotics during hospitalization for an average of 2.7 weeks. Steroids were prescribed for 52% of patients and tumor necrosis factor alpha (TNF-alpha) antagonists for 17%. Surgical resection was required for 33 patients (44% of the cohort) while 51% were managed with antibiotics and/or percutaneous drainage. The most common surgical intervention was ileocecal resection (45%). Although patients who underwent follow-up imaging were more likely to require early surgical intervention (P = 0.04), no statistically significant predictor of surgery could be identified from this cohort. Time to surgery varied numerically according to abscess size (HR = 1.18, 95% CI = 0.62-2.27, P = 0.61). Conclusions: Although the majority of patients with CD-related intra-abdominal collections underwent surgical resection in this cohort, no obvious predictors of surgical intervention could be identified. The decision to perform early surgery appeared to be influenced by the findings observed on cross-sectional imaging during the follow-up of these collections.
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© 2021 Saudi Journal of Gastroenterology | Published by Wolters Kluwer ‑ Medknow 1
Clinical characteristics, natural history, and outcomes of
Crohn’s‑related intra‑abdominal collections
Othman Alharbi, Majid A. Almadi, Nahla Azzam, Abdulrahman M. Aljebreen, Turki AlAmeel1, Stefan Schreiber2,
Mahmoud H. Mosli3
Department of  Medicine, Division of Gastroenterology, King Khalid Hospital, King Saud University Medical City, King Saud University,
Riyadh, 1Department of Medicine, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia, 2Department of Internal Medicine,
Instute of Clinical Molecular Biology, Chrisan‑Albrechts‑University, University Hospital Schleswig‑Holstein (UKSH), Campus Kiel, Kiel,
Germany, 3Department of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi  Arabia
Original Article
Background: Intra‑abdominal collections in the form of abscesses or matted bowel loops, called phlegmons,
might occur in patients with Crohn’s disease (CD). The clinical characteristics and management of such
conditions are not well described. We aim to characterize CD‑related intra‑abdominal collections clinically,
and identify predictors of need for surgical interventions and the time to surgery.
Methods: We utilized the Saudi Inflammatory Bowel Disease Information System (IBDIS) database to identify
all patients treated for radiologically proven intra‑abdominal abscesses or phlegmons since inception.
Demographics, clinical data, clinical course, and treatment outcomes were recorded. Logistic regression
analysis and survival analysis were used to identify predictors of surgical resection and differences in time
to surgery between patient subgroups, respectively.
Results: A total of 734 patients with a diagnosis of CD were screened and 75 patients were identified. The mean
age was 25.6 ± 9.9 years and 51% were males. Nearly 60% of patients had abscesses larger than 3 cm while 13%
had smaller abscesses and 36% had phlegmons. On presentation, the most commonly reported symptom was
abdominal pain (99%) followed by weight loss (27%). About 89% of patients were treated with antibiotics during
hospitalization for an average of 2.7 weeks. Steroids were prescribed for 52% of patients and tumor necrosis factor
alpha (TNF‑alpha) antagonists for 17%. Surgical resection was required for 33 patients (44% of the cohort) while
51% were managed with antibiotics and/or percutaneous drainage. The most common surgical intervention
was ileocecal resection (45%). Although patients who underwent follow‑up imaging were more likely to require
early surgical intervention (P = 0.04), no statistically significant predictor of surgery could be identified from this
cohort. Time to surgery varied numerically according to abscess size (HR = 1.18, 95% CI = 0.62–2.27, P = 0.61).
Conclusions: Although the majority of patients with CD‑related intra‑abdominal collections underwent
surgical resection in this cohort, no obvious predictors of surgical intervention could be identified. The
decision to perform early surgery appeared to be influenced by the findings observed on cross‑sectional
imaging during the follow‑up of these collections.
Keywords: Abscess, collection, Crohn’s disease, outcome, phlegmon, surgery
Address for correspondence: Dr. Othman Alharbi, Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh,
Kingdom of Saudi Arabia.
E‑mail: Othmanalharbi@ksu.ed.sa
Submied: 08‑Mar‑2020 Revised: 09‑May‑2020 Accepted: 16‑Aug‑2020 Published: 12‑Mar‑2021
Access this article online
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DOI:
10.4103/sjg.SJG_89_20
How to cite this article: Alharbi O, Almadi MA, Azzam N, Aljebreen AM,
AlAmeel T, Schreiber S, et al. Clinical characteristics, natural history,
and outcomes of Crohn’s‑related intra‑abdominal collections. Saudi J
Gastroenterol 0;0:0.
Abstract
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Alharbi, et al.: Outcomes of Crohn’s‑related abdominal collections
2 Saudi Journal of Gastroenterology | Volume XX | Issue XX | Month 2021
INTRODUCTION
Crohn’s disease (CD) is an autoimmune bowel disorder
characterized by chronic transmural inammation that
can affect any part of the gastrointestinal system. It
has the potential for progressing to local and systemic
complications secondary to unopposed inammation.[1]
Local complications of CD include stulas, abscesses,
strictures, and bowel perforation depending on disease
phenotype and location.[2] The disease can manifest as
one of three phenotypes: inammatory, bro‑stenotic,
or penetrating behavior as defined by the Montreal
classication.[3] CD involves the ileocolonic region in up
to 45% of cases.[4,5] These factors in addition to age and
gender might play a role in the formation of local disease
complications.[6]
Conventional step‑up therapy is an appropriate treatment
approach for CD patients with low‑risk features. Early
introduction of biologics is more effective in patients
with high‑risk features such as stulizing phenotype and
early age at the time of diagnosis.[7] It is not clear if early
treatment inuences important outcomes such as the
development of intra‑abdominal collections.[8]
Intra‑abdominal collections such as abscesses and
phlegmons are not well characterized in the literature.
Although a standardized definition does not exist,
phlegmons are generally described as inammatory masses
that are composed of matted loops of bowel without any
clear uid collection. This is how they are distinguished
from abscesses on cross‑sectional imaging. The latter has
a clearly dened collection with or without matted loops
of bowel.
Treatment options in cases of intra‑abdominal collections
include a conservative approach with percutaneous
drainage and antimicrobial therapy or surgical intervention.
The natural history and correct treatment of phlegmons
are not well‑characterized. Whether or not phlegmons
can be effectively and safely treated with TNF antagonists
is uncertain. A small retrospective analysis by Cullen
et al. suggested that anti‑TNF therapy might be effective
for phlegmons.[6,9] However, some experts suggest
that surgical resection should always be performed
in cases of phlegmons due to the high recurrence
rates.[10‑15] Furthermore, predictors of the need for surgical
intervention in phlegmon remain unknown.
This study aims to characterize CD‑related intra‑abdominal
collections and to identify predictors of the need for
surgical resection.
PATIENTS AND METHODS
The Inflammatory Bowel Disease Information
System (IBDIS) is a centralized database that is used to
register all the patients (total number 1294) diagnosed
with IBD enrolled in major medical centers in the
Kingdom of Saudi Arabia (KSA). IBDIS (www.ibdis.
net) is a web‑based documentation system comprising
of multiple blocks of information including IBD‑related
parameters such as demographics, risk factors, diagnosis,
disease location and behavior, course of the disease,
extra‑intestinal manifestations, complications, pregnancy,
surgical, and conservative therapy (dened as antibiotics
and or percutaneous drainage). Further description of the
registry has been outlined in a previous publication.[4,16‑20]
From the IBDIS registry, we identied all patients who had a
radiologically conrmed diagnosis of abscess or phlegmon
based on ultrasound (US), computed tomography (CT),
or magnetic resonance imaging (MRI) of the abdomen.
A phlegmon was dened as a spontaneously occurring
inammatory mass adjacent to an area of inamed/matted
bowel loops that lacks any evidence of a uid collection[9]
and an abscess as any extra‑luminal uid collection.
Patient demographics and clinical data at the time of
phlegmon diagnosis were recorded. This included their
age, gender, duration of disease, disease phenotype
according to the Montreal classication, disease extent/
location, past and present medications including steroids,
immunosuppressives, antibiotics, or TNF‑alpha antagonist
use, cigarette smoking, and clinical symptoms. Laboratory
and radiology investigations including complete blood
count (CBC), C‑reactive protein, and erythrocyte
sedimentation rate (ESR), were also recorded.
Outcomes
Surgical resection of small or large bowel segments due to
the presence of an inammatory mass or uid collection
was considered the main outcome. Time to surgery was
considered the secondary outcome.
Statistical analysis
Convenient sample size was utilized for analysis. Baseline
means and standard deviations (SD) were calculated for
continuous variables, while frequencies and percentages
were calculated for categorical variables.
Simple logistic regression analysis was used to identify
predictors of surgical resection. When permitted, multiple
logistic regression analysis was attempted depending on the
number of variables and observations, and multinomial
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Alharbi, et al.: Outcomes of Crohn’s‑related abdominal collections
Saudi Journal of Gastroenterology | Volume XX | Issue XX | Month 2021 3
logistic regression analysis was used if the dependent
variable had more than two categories with relative
risk (RR) ratios reported. A Kaplan‑Meier curve was used
to estimate and compare time to surgery among groups of
patients. Cox proportional regression analysis was used to
compare time to events using hazard ratio (HR) estimates.
The precision of point estimate was estimated using 95%
condence intervals (CI). STATA 11.2 (StataCorp, Texas,
USA) with a signicance level of 5%.
Ethical approval
This study was conducted in accordance with the protocol
and principles of the Declaration of Helsinki. The study
was approved by the Ethical Committee of the Institute
for IBD Database registry with IRB project No. E‑11‑538.
RESULTS
Baseline characteristics
The baseline characteristics of 75 included patients are
described in Table 1. The mean age was 25.6 ± 9.9 years,
54% of patients in this cohort were older than age 40,
and 51% were males. The mean duration of disease was
28 ± 43 months and the most common form of disease
distribution was an ileocolonic disease (54%). About
60% of patients had abscesses that had a diameter larger
than 3 cm. Smaller abscesses were found in 13% while
36% of patients had a phlegmon. On presentation, the
most commonly reported symptoms were abdominal
pain (99%) and weight loss (27%). Use of corticosteroids,
azathioprine (AZA), and 5‑ASA agents were reported in
50%, 48%, and 42%, respectively and only 11% of patients
were on a TNF‑alpha antagonist at the time of diagnosis
of an intra‑abdominal collection. The average duration of
follow‑up following the diagnosis of an intra‑abdominal
collection was 0.5 ± 0.6 years.
Predictors of abscess formation
Males were more likely to have smaller abscesses (RR = 11.2,
95% CI = 0.81–16, P = 0.07) and phlegmons (RR = 41.6,
95% CI = 2.21–784.28, P = 0.01) compared to females.
A numerically higher percentage of patients had vomiting
as the presenting symptom of phlegmon formation
compared to patients with large abscesses (RR = 8.24, 95%
CI = 0.86–78.62, P = 0.07).
Hospital course and outcomes
The average duration of hospitalization was
16.3 ± 10.5 days. Antibiotics were prescribed to 89% of
patients. Corticosteroids were prescribed for 52% while
AZA was prescribed for 72% of the cases. Only 17% of the
patient cohort received anti‑TNF therapy (Supplementary
Figure 1).
The average time to surgical intervention, which was
required for 44% of patients, was 4.1 ± 9.4 weeks and
the most common surgical intervention was ileocecal
resection (45%). Perforation occurred in 4% of patients.
For patients who completed 1 year of follow‑up, 56% were
surgery‑free following conservative therapy, 36% eventually
required surgery, and 5% underwent a second surgical
intervention. Radiological follow‑up of intra‑abdominal
collections occurred in 70% of cases. Patients who
underwent follow‑up imaging were more likely to require
early surgical intervention (P = 0. 04). Hospital course and
treatments are described in Table 2.
Predictors of surgical resection
On simple and multiple regression analysis, no statistically
signicant predictor of the need for surgical resection could
be identied. The only exception was weight loss; dened
as a 15% decline in body weight within the preceding 2
months, which was statistically signicant according to
Table 1: Baseline characteristics of 75 patients with Crohn’s-
related intra-abdominal collections
Age (mean±SD)
- <40 (A1)
- >40 (A2)
25.6±9.9
46%
54%
BMI (mean±SD) 18.8±4.5
Disease duration in months (mean±SD) 28±42.5
Male gender (%) 38 (51)
Cigarette smoking (%) 11 (15)
Disease location (%)
Ileal (L1)
Colonic (L2)
Ileocolonic (L3)
34 (45)
1 (1)
40 (54)
Lesion Type (%)
Abscess > 3 cm
Phlegmon
Abscess < = 3 cm
44 (59)
21 (28)
10 (13)
Symptoms (%)
Abdominal pain
Weight loss
Diarrhea
Vomiting
Abdominal Mass
Fever
74 (99)
20 (27)
15 (20)
13 (17)
9 (12)
7 (9)
Vital signs on presentation (Mean±SD)
Heart rate
Respiratory rate
Temperature
99±20
20.5±1.2
37.5±4.5
Medications at baseline (%)
5-ASA
Corticosteroids
Azathioprine
Anti-TNF agents
33 (44)
32 (43)
31 (41)
7 (9)
Laboratory investigations
Hemoglobin (g/dL)
Platelets
WBC count
CRP
ESR
108.5±25.9
453±146.7
9.9±4.6
72±78.5
55±32.6
Duration of follow-up in months (mean±SD) 6±7.2
*SD: Standard deviation, BMI; body mass index, ASA; aminosalicylic
acid, WBC; white blood cell, CRP; C-reactive protein, ESR; erythrocyte
sedimentation rate
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Alharbi, et al.: Outcomes of Crohn’s‑related abdominal collections
4 Saudi Journal of Gastroenterology | Volume XX | Issue XX | Month 2021
simple (OR = 3.8, 95% CI = 1.29–1.22) but not to multiple
logistic regression analysis [Table 3].
Time to surgery
Time to surgical resection was stratied according to the
type of intra‑abdominal collection using the Kaplan‑Meier
curve [Figure 1]. A large variation was observed between
the three groups with the longest time to surgery observed
with large abscesses (>3 cm). However, based on Cox
proportional regression analysis, no statistical signicance
was observed when comparing time to surgery between
the three types of collections (HR = 1.18, 95% CI = 0.62
to 2.27, P = 0.61).
DISCUSSION
Persistence of disease activity is associated with the
development of intra‑abdominal abscesses and phlegmons
in patients with CD. This could be attributed to the
transmural nature of inammation seen in CD. Limited
data suggest that phlegmons can be safely treated with TNF
antagonists[9] in the presence of antibiotics. The use of TNF
antagonists in this population did not lead to an increase
in the size of abdominal collections. Nonetheless, many
physicians will be concerned about abscess expansion and
the development of complications such as perforation with
immunosuppressive treatment.[21] Therefore, it is essential
to differentiate intra‑abdominal and pelvic collections from
phlegmons. While cross‑sectional imaging can accurately
differentiate between these lesions and help estimate their
sizes,[22] it is difcult to distinguish between them clinically.
In our cohort, the only symptom found to be predictive
of phlegmon formation when compared to abscesses was
vomiting, which likely occurs due to obstructed bowel.
Generally, larger lesions are considered at higher risk for
free perforation. Based on our data, most collections
developed in the ileocecal region and were larger than 3 cm
in diameter. Furthermore, men appeared to have smaller
collections compared to female patients and perforation,
a fearful complication of intra‑abdominal collections
occurred in only 9% of the cases. Moreover, consequences
of leaving an abscess without drainage or relying solely on
antibiotics for treatment are not well‑studied, yet available
data suggests that treatment with antibiotics alone can
lead to resolution of up to two‑thirds of abscesses but
with a recurrence rate that exceeds 50%.[23‑25] In addition
to antimicrobial therapy, both image‑guided percutaneous
drainage and surgical resection are treatment options
with comparable outcomes.[14,26,27] While no randomized
controlled studies have compared the two approaches,
surgical resection is believed to be superior to percutaneous
drainage based on retrospective data.[28] Nevertheless, the
perioperative morbidity and mortality associated with
surgical resection during the acute stages is the main reason
why percutaneous drainage should rst be attempted.[29]
In a multicenter study that involved 128 CD patients with
intra‑abdominal abscesses, surgical intervention appeared
to be the most effective treatment strategy compared to
Table 2: Treatment and hospitalization course of 75 patients
with Crohn’s disease
Duration of treatment in weeks (mean±SD)
Corticosteroids (%)
Duration of treatment in weeks (mean±SD)
Dosage in milligrams (mean±SD)
Azathioprine (%)
Anti-TNF (%)
Adalimumab 40 mg once weekly
Adalimumab 40 mg every 2 weeks
Infliximab 5–10 mg/kg
2.7±1.7
39 (52)
4.1±9.4
17.8±16.5
54 (72)
13 (17)
1 (8)
1 (8)
11 (84)
Duration of hospitalization in days 16.3±1.4
Types of Surgical resection (%)
Ileocecal resection
Ileal resection
Right hemicolectomy
Vesico-enteric fistula repair
Small bowel resection
Total colectomy
Subtotal colectomy
Left hemicolectomy
Time to Surgery in weeks (mean±SD)
33 (44)
16 (48)
6 (19)
3 (10)
3 (10)
2 (6)
2 (6)
1 (3)
1 (3)
4.1 + -9.4
Timing of surgery (%):
- None
- < 2 months
- > 2 months
42 (56)
24 (32)
9 (12)
Perforation (%) 3 (4)
Follow-up imaging (%) 37 (49)
Outcome after 1 year of follow-up:
- Need for surgical intervention
- Resolution with conservative therapy
- Need for surgery following conservative treatment
- Need for a second surgery
33 (44)
42 (56)
15 (36)
4 (5)
*SD; standard deviation, TNF; tumor necrosis factor
Table 3: Simple and multiple linear regression analysis of
predictors of surgical resection for intra-abdominal collections
Variable Univariate OR
(95% CI)
Multivariate OR
(95% CI)
Type of collection 0.94 (0.44,1.93) 19.81 (0.52,759.98)
Gender 0.89 (0.37, 2.35) 840.66 (0.025, 2.84e+07)
Duration of disease in
months
0.99 (0.98, 1.00) 0.99 (0.91, 1.08)
Smoking 1.22 (0.33, 4.41) 0.12 (0.001, 15.16)
Weight loss 3.8 (1.29, 11.22) 562.55 (0.036, 8774450)
Age 0.99 (0.95, 1.04) 1.68 (0.72, 3.95)
Extent of disease 1.01 (0.63, 1.61) 9.58 (0.38, 239)
Baseline use of 5-ASA 0.43 (0.31, 2.28) 0.02 (0.0001,2.46)
Baseline use of AZA 0.52 (0.19, 1.41) 0.02 (0.00002,36.67)
Baseline use of
steroids
0.30 (0.22, 1.62) 0.24 (0.006,9.40)
Baseline use of TNF
antagonists
0.96 (0.19, 4.69) 26.42 (0.02,31802)
Baseline CRP 1.00 (0.99, 1.01) 1.03 (0.98,1.09)
Duration of antibiotics
use
1.05 (0.79, 1.41) 1.84 (0.12,27.23)
OR; odds ratio, CI; confidence interval, ASA; aminosalicylic acid, AZA;
azathioprine, TNF; tumor necrosis factor, CRP; C-reactive protein
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Alharbi, et al.: Outcomes of Crohn’s‑related abdominal collections
Saudi Journal of Gastroenterology | Volume XX | Issue XX | Month 2021 5
percutaneous drainage and antibiotic therapy. Antibiotic
therapy was more likely to fail in the presence of larger
abscesses (OR = 1.65; 95% CI 1.07–.54; P = 0.02),
stulas (OR = 5.43; 95% CI 1.18–24.8; P = 0.02), and
treatment with immunosuppressants (OR = 8.45; 95%
CI = 1.16–61.5; P = 0.03).[30] Nearly 44% of our patient
cohort underwent surgery; most of which involved the right
side of the colon and terminal ileum. Conservative therapy
including antibiotic use in combination with percutaneous
drainage led to the resolution of abscesses in 51% of
patients, surgical intervention was required following
treatment with antibiotics in 36% of cases, and 7% required
a second operation. Although our results showed that
patients who underwent follow‑up imaging were more
likely to require early surgical intervention (P = 0. 04),
likely due to selection bias i.e., symptomatic patients were
more likely to undergo follow‑up imaging and hence more
likely to have positive ndings that would require surgery,
no obvious predictors of surgery could be identied in
this cohort nor were there any signicant differences
observed between times to surgery based on collection size.
Endoscopic intervention has been proposed as a novel
method for draining collections in patients with CD. This
remains an experimental method and should be restricted
to research settings.
We acknowledge that our results might be biased due to the
retrospective method of collecting data and small sample
size. Large, prospectively conducted studies are needed to
better evaluate outcomes of CD‑related intra‑abdominal
collections and compare different types in treatment.
CONCLUSIONS
Crohn’s‑related intra‑abdominal collections are difcult
to identify clinically without cross‑sectional imaging of
the abdomen and differentiating between abscesses and
phlegmons using clinical evaluation remains challenging.
The majority of this cohort required surgical intervention
within 1 year of presenting with a collection, including
those treated conservatively (51/75), and for those who
did require surgical intervention, no obvious clinical
markers could be relied upon to predict average time to
surgery. Large randomized controlled trials are needed to
identify the optimal treatment approach for phlegmons
and abscesses.
Financial support and sponsorship
The authors extend their sincere appreciation to the
Deanship of Scientic Research at King Saud University
for its funding of this research through the Research Group
Project number RGP‑279.
Conflicts of interest
There are no conicts of interest.
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[Downloaded free from http://www.saudijgastro.com on Thursday, March 18, 2021, IP: 178.80.131.16]
Supplementary Figure 1: Treatment of Crohn’s disease-related
intra-abdominal collections
[Downloaded free from http://www.saudijgastro.com on Thursday, March 18, 2021, IP: 178.80.131.16]
... International guidelines recommend intravenous antibiotic therapy and therapeutic (percutaneous) drainage if abscess formation exceeds 3 cm in diameter [6,[9][10][11]. So far, empiric antibiotic therapy included a combination of metronidazole with fluoroquinolones or third generation cephalosporins [6,18], but these recommendations are mainly based on case series and retrospective monocentric data, respectively [15,[19][20][21][22][23][24][25][26][27][28][29][30][31]. In line with that, a recently published multicentric prospective European study evaluating the microbial spectrum of intra-abdominal abscess formation in patients suffering from Crohn s disease demonstrated a high rate of inadequate antimicrobial empirical first-line therapy [16]. ...
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Intraabdominal abscess formation occurs in up to 30% of patients suffering from Crohn´s disease (CD). While international guidelines recommend a step-up approach with a combination of empiric antibiotic therapy and percutaneous drainage to delay or even avoid surgery, evidence about microbial spectrum in penetrating ileitis is sparse. We retrospectively assessed outcomes of 46 patients with terminal penetrating Ileitis where microbial diagnostics have been performed and compared microbial spectrum and antibiotic resistance profile of CD patients with patients suffering from diverticulitis with intraabdominal abscess formation. In both groups, the most frequently isolated pathogen was the gram-negative bacterium E. coli belonging to the family of Enterobacterales. However, overall Enterobacterales were significantly more often verifiable in the control group than in CD patients. Furthermore, microbial analysis showed significant differences regarding isolation of anaerobic pathogens with decreased frequency in patients with CD. Subgroup analysis of CD patients to evaluate a potential influence of immunosuppressive therapy on microbial spectrum only revealed that Enterobacterales was less frequently detected in patients treated with steroids. Immunosuppressive therapy did not show any impact on all other groups of pathogens and did not change antibiotic resistance profile of CD patients. In conclusion, we were able to demonstrate that the microbial spectrum of CD patients does differ only for some pathogen species without increased rate of antibiotic resistance. However, the empiric antibiotic therapy for CD-associated intra-abdominal abscess remains challenging since different points such as local epidemiological and microbiological data, individual patient risk factors, severity of infection, and therapy algorithm including non-surgical and surgical therapy options should be considered before therapeutical decisions are made.
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We determined the association between vitamin D status as 25hydroxyvitamin D [25(OH)D] and disease activity in a cohort of 201 Crohn’s Disease (CD) patients in Saskatoon, Canada over three years. The association between high-sensitivity C-reactive protein (hs-CRP) and 25(OH)D and several disease predictors were evaluated by the generalized estimating equation (GEE) over three time-point measurements. A GEE binary logistic regression test was used to evaluate the association between vitamin D status and the Harvey-Bradshaw Index (HBI). The deficient vitamin D group (≤29 nmol/L) had significantly higher mean hs-CRP levels compared with the three other categories of vitamin D status (p < 0.05). CRP was significantly lower in all of the other groups compared with the vitamin D-deficient group, which had Coef. = 12.8 units lower (95% CI −19.8, −5.8), Coef. 7.85 units (95% CI −14.9, −0.7), Coef. 9.87 units (95% CI −17.6, −2.0) for the vitamin D insufficient, adequate, and optimal groups, respectively. The vitamin D status was associated with the HBI active disease category. However, the difference in the odds ratio compared with the reference category of deficient vitamin D category was only significant in the insufficient category (odds ratio = 3.45, p = 0.03, 95% CI 1.0, 10.8). Vitamin D status was inversely associated with indicators of disease activity in Crohn’s disease, particularly with the objective measures of inflammation.
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Background/Aims: Ghrelin and leptin are thought to play a role in the loss of appetite in active inflammatory bowel disease (IBD). This study seeks to probe into the association of these markers with regards to IBD and the nutritional status of these patients. A case-control study was conducted between May 2015 and March 2016 at King Khalid University Hospital (KKUH). Thirty-one patients with IBD (both active and non-active) and forty-one healthy controls (both non-fasting and fasting) were recruited. Patients and Methods: Plasma ghrelin and leptin levels were determined using an enzyme immunoassay (EIA) technique. The nutritional status was determined through the standardized Mini-Nutritional Assessment (MNA) questionnaire. Results: The difference in the plasma ghrelin between active (263.7 pg/mL) and non-active (108 pg/mL) cases was significant (P= 0.02). The difference in mean plasma leptin level between active cases (229.4 pg/mL) vs. non-active cases (359.7 pg/mL) was insignificant (P= 0.4). In fasting (2028.6 pg/mL) and non-fasting controls (438.8 pg/mL), the mean plasma ghrelin values was significantly different (P< 0.01). In contrast, the plasma leptin level difference between fasting (727.3 pg/mL) and non-fasting (577 pg/mL) controls was insignificant (P= 0.14). There is a statistically significant association in mean ghrelin levels between the case group and the control group (P< 0.01). With regards to nutritional status, the mean MNA score of active cases compared to fasting controls was 18.8 ± 5 vs. 20.8 ± 3.8, respectively (P< 0.01) Conclusion: Ghrelin levels were lower in the active IBD cases compared to the inactive ones, signifying an underlying pathology as etiology to this phenomenon. Furthermore, ghrelin levels were significantly lower in both case groups compared to the controls. These findings, along with the disparity in the MNA scores, insinuate a possible link between hormone levels and the loss of appetite from which these patients suffer.
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Background and aims: Spontaneous intra-abdominal abscess formation is a common complication of Crohn's disease. Percutaneous drainage (PD) may avoid surgery and preserve bowel length although there is no consensus on its efficacy as the initial treatment and the associated outcomes if unsuccesful. This study uses meta-analytical techniques to compare the outcomes of PD alone versus primary surgery for Crohn's related intra-abdominal abscess. Methods: A comprehensive search for comparative studies examining the use of PD and surgery for spontaneous Crohn's related intra-abdominal abscess was performed. Each study was reviewed and data extracted. Random-effects methods were used to combine data. Results: There were 6 studies including a total of 333 patients that met the inclusion criteria. Surgery was performed initially in 184 patients, PD was performed in 149. Groups were similar in demographics and abscess characteristics. There was a significantly higher risk of abscess recurrence following PD (OR: 6.544, 95% CI: 1.783-24.010, P: 0.005). The pooled proportion of PD patients requiring subsequent surgery was 70.7%. There was no significant difference between approaches in post-procedural complication rate (OR: 0.657, 95% CI: 0.175-2.476, P: 0.535), ultimate permanent stoma requirement (OR: 0.557, 95% CI: 0.147-2.111, P: 0.389) or length of hospital stay (difference in means: -1.006 days, 95% CI: -28.762-26.749, P: 0.943). Conclusions: PD can avoid surgery in up to 30% of patients presenting with spontaneous Crohn's related intra-abdominal abscesses, however, the suggested advantages over surgery in relation to complications and length of stay were not apparent. Further studies in this area are needed.
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Background and aims: Perianal fistulizing Crohn's disease (PFCD) leads to significant disability. Data assessing healing of complex PFCD based on pelvic MRI using Parks' classification remains sparse. We aimed to assess the frequency of closure of fistula tract on MRI in patients treated with antitumor necrosis factor alpha antagonists and identify predictors of poor response. Materials and methods: We retrospectively identified patients registered in the Saudi Inflammatory Bowel Disease Information System registry, who were diagnosed as PFCD based on MRI and treated with infliximab or adalimumab. Fistulae were classified based on Parks' classification and response to treatment was determined as full, partial, or no response, after at least 12 months of treatment. Results: Out of 960 patients, 61 had complex PFCD that required treatment with an anti-TNF agent. The median age was 27 years (range: 14-69 years) and the median duration of disease was 6.2 ± 5.8 years. A full response to treatment was achieved in 27 (44.4%), whereas 10 patients (16.3%) had partial response and 24 (39.3%) had no response. On univariable analysis, a statistically significant association was observed between poor fistula response and low BMI, rectal involvement, fistulae classification, and the presence of an abscess. According to multivariable regression, only low BMI predicted poor fistulae outcome (odds ratio = 1.37, 95% confidence interval: 0.69-0.98). Conclusion: Less than half of this cohort of patients with PFCD achieved complete radiological fistula healing with anti-TNF therapy. Low BMI appears to be the only predictor of poor outcome.
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Objective The Epi-IBD cohort is a prospective population-based inception cohort of unselected patients with inflammatory bowel disease from 29 European centres covering a background population of almost 10 million people. The aim of this study was to assess the 5-year outcome and disease course of patients with Crohn’s disease (CD). Design Patients were followed up prospectively from the time of diagnosis, including collection of their clinical data, demographics, disease activity, medical therapy, surgery, cancers and deaths. Associations between outcomes and multiple covariates were analysed by Cox regression analysis. Results In total, 488 patients were included in the study. During follow-up, 107 (22%) patients received surgery, while 176 (36%) patients were hospitalised because of CD. A total of 49 (14%) patients diagnosed with non-stricturing, non-penetrating disease progressed to either stricturing and/or penetrating disease. These rates did not differ between patients from Western and Eastern Europe. However, significant geographic differences were noted regarding treatment: more patients in Western Europe received biological therapy (33%) and immunomodulators (66%) than did those in Eastern Europe (14% and 54%, respectively, P<0.01), while more Eastern European patients received 5-aminosalicylates (90% vs 56%, P<0.05). Treatment with immunomodulators reduced the risk of surgery (HR: 0.4, 95% CI 0.2 to 0.6) and hospitalisation (HR: 0.3, 95% CI 0.2 to 0.5). Conclusion Despite patients being treated early and frequently with immunomodulators and biological therapy in Western Europe, 5-year outcomes including surgery and phenotype progression in this cohort were comparable across Western and Eastern Europe. Differences in treatment strategies between Western and Eastern European centres did not affect the disease course. Treatment with immunomodulators reduced the risk of surgery and hospitalisation.
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Background and aims: Complications such as need for bowel resections and hospitalization due to Crohn's disease (CD) occur when disease activity persists due to ineffective therapy. Certain "high-risk" features require an early introduction of anti-tumor necrosis factor-α therapy to prevent such complications. We aim to evaluate the prevalence of "high-risk" features among a cohort of patients with CD and examine the association between discordance of early therapy with baseline risk stratification and disease outcome. Patients and methods: All adult patients with CD were retrospectively identified and their medical records were reviewed. Clinical, endoscopic, laboratory, and radiological data were collected. Patients were divided into "low" and "high" risk groups according to the presence or absence of penetrating disease, perianal involvement, foregut involvement, extensive disease seen on endoscopy or cross-sectional imaging, young age at the time of diagnosis (<40), persistent cigarette smoking and frequent early requirements for corticosteroid therapy. Initial treatment selection and treatment approach ("step-up" vs. "accelerated step-up" vs. "top-down") within 6 months of diagnosis were recorded. Rates of CD-related bowel resections and hospitalization within 5 years of diagnosis were calculated. Logistic regression analysis was used to examine the association between "discordance" of early treatment selections and risk stratification categories with outcomes. Results: Eighty-five CD patients were included. The median age and duration of disease were 25 (interquartile range [IQR] 19-32) and 5 (IQR 4-6) years, respectively. Sixty five percent were females and 66% were native Saudis. Smoking was reported in 12% of patients and perianal disease in 18%. "High-risk" features were identified in 43 (51%) patients, of which only 6 (14%) were treated with "top-down" therapy and 7 (16%) with "accelerated step-up" care. The risk of requiring a bowel resection, and hospitalization was higher for "high-risk" patients compared to "low-risk" patients (risk ratio [RR] 13.67, 95% CI 1.88-99.41; p = 0.003, and RR 1.86, 95% CI 0.03-0.43; p = 0.0312, respectively). "Discordance" occurred in 34% of cases. Bowel resection was required in 15/85 (18%) patients and 32/85 (38%) required at least one hospitalization within 5 years of diagnosis. Logistic regression analysis identified a statistically significant association between "discordance" and need for bowel resections (OR 6.50, 95% CI 1.59-26.27, p = 0.009), and hospitalizations (OR 3.01, 95% CI 1.08-8.39, p = 0.035) within 5 years of diagnosis. Conclusions: "Discordance" between patient risk-profile and treatment selection early in the course of CD has a significant impact on disease outcome, specifically need for bowel resection and hospitalization, which are more likely to occur in the presence of "high-risk" features. Early identification of "high-risk" features could help prevent long-term complications.
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Crohn disease is a chronic idiopathic inflammatory bowel disease condition characterized by skip lesions and transmural inflammation that can affect the entire gastrointestinal tract from the mouth to the anus. For this review article, we performed a review of articles in PubMed through February 1, 2017, by using the following Medical Subject Heading terms: crohns disease, crohn's disease, crohn disease, inflammatory bowel disease, and inflammatory bowel diseases. Presenting symptoms are often variable and may include diarrhea, abdominal pain, weight loss, nausea, vomiting, and in certain cases fevers or chills. There are 3 main disease phenotypes: inflammatory, structuring, and penetrating. In addition to the underlying disease phenotype, up to a third of patients will develop perianal involvement of their disease. In addition, in some cases, extraintestinal manifestations may develop. The diagnosis is typically made with endoscopic and/or radiologic findings. Disease management is usually with pharmacologic therapy, which is determined on the basis of disease severity and underlying disease phenotype. Although the goal of management is to control the inflammation and induce a clinical remission with pharmacologic therapy, most patients will eventually require surgery for their disease. Unfortunately, surgery is not curative and patients still require ongoing therapy even after surgery for disease recurrence. Importantly, given the risks of complications from both Crohn disease and the medications used to treat the disease process, primary care physicians play an important role in optimizing the preventative care management to reduce the risk of complications.
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Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract, with increasing incidence worldwide. Crohn's disease might result from a complex interplay between genetic susceptibility, environmental factors, and altered gut microbiota, leading to dysregulated innate and adaptive immune responses. The typical clinical scenario is a young patient presenting with abdominal pain, chronic diarrhoea, weight loss, and fatigue. Assessment of disease extent and of prognostic factors for complications is paramount to guide therapeutic decisions. Current strategies aim for deep and long-lasting remission, with the goal of preventing complications, such as surgery, and blocking disease progression. Central to these strategies is the introduction of early immunosuppression or combination therapy with biologicals in high-risk patients, combined with a tight and frequent control of inflammation, and adjustment of therapy on the basis of that assessment (treat to target strategy). The therapeutic armamentarium for Crohn's disease is expanding, and therefore the need to develop biomarkers that can predict response to therapies will become increasingly important for personalised medicine decisions in the near future. In this Seminar, we provide a physician-oriented overview of Crohn's disease in adults, ranging from epidemiology and cause to clinical diagnosis, natural history, patient stratification and clinical management, and ending with an overview of emerging therapies and future directions for research.
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IBD, comprising Crohn's disease and ulcerative colitis, is a chronic immunologically mediated disease at the intersection of complex interactions between genetics, environment and gut microbiota. Established high-prevalence populations of IBD in North America and Europe experienced the steepest increase in incidence towards the second half of the twentieth century. Furthermore, populations previously considered 'low risk' (such as in Japan and India) are witnessing an increase in incidence. Potentially relevant environmental influences span the spectrum of life from mode of childbirth and early-life exposures (including breastfeeding and antibiotic exposure in infancy) to exposures later on in adulthood (including smoking, major life stressors, diet and lifestyle). Data support an association between smoking and Crohn's disease whereas smoking cessation, but not current smoking, is associated with an increased risk of ulcerative colitis. Dietary fibre (particularly fruits and vegetables), saturated fats, depression and impaired sleep, and low vitamin D levels have all been associated with incident IBD. Interventional studies assessing the effects of modifying these risk factors on natural history and patient outcomes are an important unmet need. In this Review, the changing epidemiology of IBD, mechanisms behind various environmental associations and interventional studies to modify risk factors and disease course are discussed.
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Several studies have also evaluated the efficacy of initial medical management compared with initial surgical management strategies with regard to abscess resolution with variable results. The aim of this study is to evaluate the efficacy of initial medical management compared with surgical management of Crohn's disease (CD)-related intra-abdominal abscesses. A comprehensive search of multiple databases (MEDLINE/PubMed, Cochrane databases, CINAHL, Scopus, and Google Scholar) was performed in August 2014. All studies on adults comparing initial surgical versus medical approaches to treat CD-related abscesses were included. The durability of abscess resolution and rate of stoma creation between the groups undergoing initial surgical versus medical approaches were compared. The pooled analysis of the nine studies including a total 603 patients showed an overall rate of abscess resolution were 56.6% in the medical group compared with 80.7% in the surgical group. There was over three-fold higher chance of achieving abscess resolution when an initial surgical strategy was used at the time of abscess diagnosis compared with the medical strategy (odds ratio 3.44, 95% confidence interval: 1.80, 6.58, P<0.001). The number needed to treat using the initial surgical approach to prevent a recurrent abscess was four patients. All included studies were retrospective case series with potential clinical confounders not fully accounted in the analysis. Initial surgical management appears to be superior to medical management in patients with CD-related intra-abdominal abscesses. Though all the included studies in this meta-analysis were retrospective, this meta-analysis is likely the strongest level of evidence with regard to the management of CD-related abscesses, given that a randomized-control trial may not be feasible given the low rate of abscess development in CD.