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Medical Tx an option for Crohn's abscesse.

For patients with Crohn's disease who have intra-abdominal abscesses, percutaneous drainage plus anti-tumor necrosis factor therapy can be as effective as surgery, Dr. Douglas L. Nguyen and his colleagues reported in the April issue of Clinical Gastroenterology and Hepatology.

"It is clear that there are lower-risk patients who can be effectively and safely managed with medical therapy In fact, we identified a subset of patients who had percutaneous drainage as an outpatient procedure and received oral antibiotics without the need for inpatient observation" said Dr Nguyen of the Mayo Clinic, Rochester, Minn., and his associates (Clin. Gastroenterol. Hepatol. 2012 April [doi: 10.1016/j.cgh.2011.11.023]).

The researchers examined this issue because until now there has been a scarcity of data on the short-or long-term outcomes of medical treatment in this setting, particularly when it involves anti-TNF agents.

"In theory, percutaneous drainage converts an intra-abdominal abscess (which is a contraindication to anti-TNF therapy) into an enterocutaneous fistula (which is an indication for anti-TNF therapy). The procedure allows an abscess cavity to safely drain, while the anti-TNF drug reduces inflammation and promotes fistula healing.

"The desired outcome would be abscess resolution and tract closure without surgical intervention," they explained.

Dr. Nguyen and his colleagues retrospectively identified 95 adults with Crohn's disease who were treated at the Mayo Clinic for abdominal or pelvic abscesses in 1999-2006. Forty of these study subjects underwent initial laparotomy with or without concomitant bowel resection.

The other 55 subjects instead had radi-ographically guided percutaneous drainage or aspiration, with or without drain placement, followed by a course of anti-TNF therapy, with or without additional immunosuppressive drug treatment.

After a median follow-up of more than 40 months, the researchers found no difference in short-and long-term recurrence between the surgical and medical management groups.

The rates of early recurrence (within 30 days) were the same between the two study groups. And the estimated 5-year cumulative rate of recurrence was 20.3% for the surgical group and 31.2% for the medical group, a nonsignificant difference.

Compared with patients who did not receive anti-TNF therapy after drainage, those who did were much less likely to develop a recurrence of abscess. Anti-TNF therapy in combination with an-other immunosuppressant - typically methotrexate, 6-mercaptopurine, or aza-thioprine - was even more protective against recurrence.

"In our cohort, there was no documentation of systemic sepsis or opportunistic infections among patients who received either anti-TNF or immunosuppressive therapy after abscess drainage," the researchers said.

Hospital stay was significantly shorter for the medical-therapy group (5 days) than the surgery group (15 days). However, the researchers postulated that perhaps patients with more severe illness, including those with multiple abscesses, were more likely to be selected for surgery This study was not randomized; instead, the treating physicians chose whether or not to operate on each patient.

Even with such selection bias, this study provides clear evidence that at least some patients can be safely and effectively managed without surgery. Twelve of the 55 patients in the medical group (22%) were managed as outpatients, the investigators noted.

The mean size or the abscess was similar between the two study groups, "indicating that size alone does not preclude successful percutaneous drainage as an initial treatment plan," they added.

In addition to abscess size, several other factors thought to raise the risk of recurrence - including patient age, length of hospitalization, medical therapy prior to drainage, history of penetrating disease, and drainage modality - were found to have no effect on risk.

A history of perianal disease and active ileal disease at the time of abscess diagnosis were the only two factors found to be significantly associated with recurrence.

Dr. Nguyen and his associates concluded that medical therapy can provide durable resolution of abscesses in Crohn's disease.

However, they said, "We do believe that there is clearly a subset of patients, including those with hemodynamic instability or long-standing fibrostenotic disease, who are better served with a surgical intervention."

Dr. Nguyen's associates reported ties to Centocor Ortho Biotech.


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Author:Moon, Mary Ann
Publication:Internal Medicine News
Date:Mar 15, 2012
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