Management of Intra-abdominal Complications of Inflammatory Bowel Disease

  • Elizabeth C. MaxwellEmail author
  • Peter Mattei
  • Andrew B. Grossman


Complex inflammatory bowel disease (IBD) including fistulizing or penetrating Crohn disease (CD) and fulminant ulcerative colitis (UC) can lead to serious complications including abscess, fistula, perforation, obstruction, and toxic megacolon which require collaboration between the gastroenterologist and surgeon. Prompt diagnosis of these entities will allow for medical optimization and surgical intervention, if required. This chapter will describe the evaluation for patients with suspected intra-abdominal complications of CD and considerations for management, with a focus on intra-abdominal and pelvic abscess resulting from internal penetrating disease. In particular, medical and surgical options for treatment will be compared. Surgical emergencies and elective procedures in CD for the indications of perforation, obstruction, and stricture will be briefly reviewed. The surgical treatment of UC is the focus of Chap.  42, but the complication of toxic megacolon will also be described here.


Penetrating disease Abscess Phlegmon Percutaneous drainage Toxic megacolon 


  1. 1.
    Feagins LA, Holubar SD, Kane SV, Spechler SJ. Current strategies in the management of intra-abdominal abscesses in Crohn’s disease. Clin Gastroenterol Hepatol. 2011;9(10):842–50.CrossRefPubMedGoogle Scholar
  2. 2.
    Pfefferkorn MD, Marshalleck FE, Saeed SA, Splawski JB, Linden BC, Weston BF. NASPGHAN clinical report on the evaluation and treatment of pediatric patients with internal penetrating Crohn disease: intraabdominal abscess with and without fistula. J Pediatr Gastroenterol Nutr. 2013;57(3):394–400.CrossRefPubMedGoogle Scholar
  3. 3.
    Jawhari A, Kamm MA, Ong C, Forbes A, Bartram CI, Hawley PR. Intra-abdominal and pelvic abscess in Crohn’s disease: results of noninvasive and surgical management. Br J Surg. 1998;85(3):367–71.CrossRefPubMedGoogle Scholar
  4. 4.
    Ayuk P, Williams N, Scott NA, Nicholson DA, Irving MH. Management of intra-abdominal abscesses in Crohn’s disease. Ann R Coll Surg Engl. 1996;78(1):5–10.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Anupindi SA, Grossman AB, Nimkin K, Mamula P, Gee MS. Imaging in the evaluation of the young patient with inflammatory bowel disease: what the gastroenterologist needs to know. J Pediatr Gastroenterol Nutr. 2014;59(4):429–39.CrossRefPubMedGoogle Scholar
  6. 6.
    Pallotta N, Civitelli F, Di Nardo G, Vincoli G, Aloi M, Viola F, et al. Small intestine contrast ultrasonography in pediatric Crohn’s disease. J Pediatr. 2013;163(3):778–84. e1CrossRefPubMedGoogle Scholar
  7. 7.
    Maltz R, Podberesky DJ, Saeed SA. Imaging modalities in pediatric inflammatory bowel disease. Curr Opin Pediatr. 2014;26(5):590–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Ripolles T, Martinez-Perez MJ, Paredes JM, Vizuete J, Garcia-Martinez E, Jimenez-Restrepo DH. Contrast-enhanced ultrasound in the differentiation between phlegmon and abscess in Crohn’s disease and other abdominal conditions. Eur J Radiol. 2013;82(10):e525–31.CrossRefPubMedGoogle Scholar
  9. 9.
    Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(2):133–64.CrossRefPubMedGoogle Scholar
  10. 10.
    de Groof EJ, Carbonnel F, Buskens CJ, Bemelman WA. Abdominal abscess in Crohn’s disease: multidisciplinary management. Dig Dis. 2014;32(Suppl 1):103–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Bermejo F, Garrido E, Chaparro M, Gordillo J, Manosa M, Algaba A, et al. Efficacy of different therapeutic options for spontaneous abdominal abscesses in Crohn’s disease: are antibiotics enough? Inflamm Bowel Dis. 2012;18(8):1509–14.CrossRefPubMedGoogle Scholar
  12. 12.
    Lorenz JM, Funaki BS, Ray Jr CE, Brown DB, Gemery JM, Greene FL, et al. ACR Appropriateness Criteria on percutaneous catheter drainage of infected fluid collections. J Am Coll Radiol. 2009;6(12):837–43.CrossRefPubMedGoogle Scholar
  13. 13.
    Kumar RR, Kim JT, Haukoos JS, Macias LH, Dixon MR, Stamos MJ, et al. Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. Dis Colon Rectum. 2006;49(2):183–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Golfieri R, Cappelli A. Computed tomography-guided percutaneous abscess drainage in coloproctology: review of the literature. Tech Coloproctol. 2007;11(3):197–208.CrossRefPubMedGoogle Scholar
  15. 15.
    Hogan MJ, Hoffer FA. Biopsy and drainage techniques in children. Tech Vasc Interv Radiol. 2010;13(4):206–13.CrossRefPubMedGoogle Scholar
  16. 16.
    Gervais DA, Hahn PF, O’Neill MJ, Mueller PR. Percutaneous abscess drainage in Crohn disease: technical success and short- and long-term outcomes during 14 years. Radiology. 2002;222(3):645–51.CrossRefPubMedGoogle Scholar
  17. 17.
    Schuster MR, Crummy AB, Wojtowycz MM, McDermott JC. Abdominal abscesses associated with enteric fistulas: percutaneous management. J Vasc Interv Radiol. 1992;3(2):359–63.CrossRefPubMedGoogle Scholar
  18. 18.
    LaBerge JM, Kerlan Jr RK, Gordon RL, Ring EJ. Nonoperative treatment of enteric fistulas: results in 53 patients. J Vasc Interv Radiol. 1992;3(2):353–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Rypens F, Dubois J, Garel L, Deslandres C, Saint-Vil D. Percutaneous drainage of abdominal abscesses in pediatric Crohn’s disease. AJR Am J Roentgenol. 2007;188(2):579–85.CrossRefPubMedGoogle Scholar
  20. 20.
    Alves A, Panis Y, Bouhnik Y, Pocard M, Vicaut E, Valleur P. Risk factors for intra-abdominal septic complications after a first ileocecal resection for Crohn’s disease: a multivariate analysis in 161 consecutive patients. Dis Colon Rectum. 2007;50(3):331–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Smedh K, Andersson M, Johansson H, Hagberg T. Preoperative management is more important than choice of sutured or stapled anastomosis in Crohn’s disease. Eur J Surg. 2002;168(3):154–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Goyer P, Alves A, Bretagnol F, Bouhnik Y, Valleur P, Panis Y. Impact of complex Crohn’s disease on the outcome of laparoscopic ileocecal resection: a comparative clinical study in 124 patients. Dis Colon Rectum. 2009;52(2):205–10.CrossRefPubMedGoogle Scholar
  23. 23.
    Laituri CA, Fraser JD, Garey CL, Aguayo P, Sharp SW, Ostlie DJ, et al. Laparoscopic ileocecectomy in pediatric patients with Crohn’s disease. J Laparoendosc Adv Surg Tech A. 2011;21(2):193–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Yamamoto T, Bain IM, Mylonakis E, Allan RN, Keighley MR. Stapled functional end-to-end anastomosis versus sutured end-to-end anastomosis after ileocolonic resection in Crohn disease. Scand J Gastroenterol. 1999;34(7):708–13.CrossRefPubMedGoogle Scholar
  25. 25.
    Iesalnieks I, Kilger A, Glass H, Obermeier F, Agha A, Schlitt HJ. Perforating Crohn’s ileitis: delay of surgery is associated with inferior postoperative outcome. Inflamm Bowel Dis. 2010;16(12):2125–30.CrossRefPubMedGoogle Scholar
  26. 26.
    He X, Lin X, Lian L, Huang J, Yao Q, Chen Z, et al. Preoperative Percutaneous Drainage of Spontaneous Intra-Abdominal Abscess in Patients With Crohn’s Disease: A Meta-Analysis. J Clin Gastroenterol. 2015;49(9):e82–90.CrossRefPubMedGoogle Scholar
  27. 27.
    Casola G. vanSonnenberg E, Neff CC, Saba RM, Withers C, Emarine CW. Abscesses in Crohn disease: percutaneous drainage. Radiology. 1987;163(1):19–22.CrossRefPubMedGoogle Scholar
  28. 28.
    Sahai A, Belair M, Gianfelice D, Cote S, Gratton J, Lahaie R. Percutaneous drainage of intra-abdominal abscesses in Crohn’s disease: short and long-term outcome. Am J Gastroenterol. 1997;92(2):275–8.PubMedGoogle Scholar
  29. 29.
    Golfieri R, Cappelli A, Giampalma E, Rizzello F, Gionchetti P, Laureti S, et al. CT-guided percutaneous pelvic abscess drainage in Crohn’s disease. Tech Coloproctol. 2006;10(2):99–105.CrossRefPubMedGoogle Scholar
  30. 30.
    Gutierrez A, Lee H, Sands BE. Outcome of surgical versus percutaneous drainage of abdominal and pelvic abscesses in Crohn’s disease. Am J Gastroenterol. 2006;101(10):2283–9.CrossRefPubMedGoogle Scholar
  31. 31.
    Nguyen DL, Sandborn WJ, Loftus Jr EV, Larson DW, Fletcher JG, Becker B, et al. Similar outcomes of surgical and medical treatment of intra-abdominal abscesses in patients with Crohn’s disease. Clin Gastroenterol Hepatol. 2012;10(4):400–4.CrossRefPubMedGoogle Scholar
  32. 32.
    Xie Y, Zhu W, Li N, Li J. The outcome of initial percutaneous drainage versus surgical drainage for intra-abdominal abscesses in Crohn’s disease. Int J Colorectal Dis. 2012;27(2):199–206.CrossRefPubMedGoogle Scholar
  33. 33.
    Cullen G, Vaughn B, Ahmed A, Peppercorn MA, Smith MP, Moss AC, et al. Abdominal phlegmons in Crohn’s disease: outcomes following antitumor necrosis factor therapy. Inflamm Bowel Dis. 2012;18(4):691–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Bruining DH, Siddiki HA, Fletcher JG, Tremaine WJ, Sandborn WJ, Loftus Jr EV. Prevalence of penetrating disease and extraintestinal manifestations of Crohn’s disease detected with CT enterography. Inflamm Bowel Dis. 2008;14(12):1701–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Present DH. Crohn’s fistula: current concepts in management. Gastroenterology. 2003;124(6):1629–35.CrossRefPubMedGoogle Scholar
  36. 36.
    Aberra FN, Lewis JD, Hass D, Rombeau JL, Osborne B, Lichtenstein GR. Corticosteroids and immunomodulators: postoperative infectious complication risk in inflammatory bowel disease patients. Gastroenterology. 2003;125(2):320–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Sands BE, Blank MA, Diamond RH, Barrett JP, Van Deventer SJ. Maintenance infliximab does not result in increased abscess development in fistulizing Crohn’s disease: results from the ACCENT II study. Aliment Pharmacol Ther. 2006;23(8):1127–36.CrossRefPubMedGoogle Scholar
  38. 38.
    Mahadevan U, Marion JF, Present DH. Fistula response to methotrexate in Crohn’s disease: a case series. Aliment Pharmacol Ther. 2003;18(10):1003–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Griffiths AM. Enteral nutrition in the management of Crohn’s disease. JPEN J Parenter Enteral Nutr. 2005;29(4 Suppl):S108–12. discussion S12-7, S84-8CrossRefPubMedGoogle Scholar
  40. 40.
    Werbin N, Haddad R, Greenberg R, Karin E, Skornick Y. Free perforation in Crohn’s disease. Isr Med Assoc J. 2003;5(3):175–7.PubMedGoogle Scholar
  41. 41.
    Freeman HJ, James D, Mahoney CJ. Spontaneous peritonitis from perforation of the colon in collagenous colitis. Can J Gastroenterol. 2001;15(4):265–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Greenstein AJ, Sachar DB, Mann D, Lachman P, Heimann T, Aufses Jr AH. Spontaneous free perforation and perforated abscess in 30 patients with Crohn’s disease. Ann Surg. 1987;205(1):72–6.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Kambouri K, Gardikis S, Agelidou M, Vaos G. Local peritonitis as the first manifestation of Crohn’s disease in a child. J Indian Assoc Pediatr Surg. 2014;19(2):100–2.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Schoepfer AM, Safroneeva E, Vavricka SR, Peyrin-Biroulet L, Mottet C. Treatment of fibrostenotic and fistulizing Crohn’s disease. Digestion. 2012;86(Suppl 1):23–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Sandborn WJ, Feagan BG, Hanauer SB, Lochs H, Lofberg R, Modigliani R, et al. A review of activity indices and efficacy endpoints for clinical trials of medical therapy in adults with Crohn’s disease. Gastroenterology. 2002;122(2):512–30.CrossRefPubMedGoogle Scholar
  46. 46.
    Pelletier AL, Kalisazan B, Wienckiewicz J, Bouarioua N, Soule JC. Infliximab treatment for symptomatic Crohn’s disease strictures. Aliment Pharmacol Ther. 2009;29(3):279–85.CrossRefPubMedGoogle Scholar
  47. 47.
    Louis E, Boverie J, Dewit O, Baert F, De Vos M, D’Haens G, et al. Treatment of small bowel subocclusive Crohn’s disease with infliximab: an open pilot study. Acta Gastroenterol Belg. 2007;70(1):15–9.PubMedGoogle Scholar
  48. 48.
    Holtmann M, Wanitschke R, Helisch A, Bartenstein P, Galle PR, Neurath M. Anti-TNF antibodies in the treatment of inflammatory intestinal stenoses in Crohn’s disease. Z Gastroenterol. 2003;41(1):11–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Hassan C, Zullo A, De Francesco V, Ierardi E, Giustini M, Pitidis A, et al. Systematic review: Endoscopic dilatation in Crohn’s disease. Aliment Pharmacol Ther. 2007;26(11–12):1457–64.CrossRefPubMedGoogle Scholar
  50. 50.
    Dietz DW, Laureti S, Strong SA, Hull TL, Church J, Remzi FH, et al. Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn’s disease. J Am Coll Surg. 2001;192(3):330–7. discussion 7-8.CrossRefPubMedGoogle Scholar
  51. 51.
    Gan SI, Beck PL. A new look at toxic megacolon: an update and review of incidence, etiology, pathogenesis, and management. Am J Gastroenterol. 2003;98(11):2363–71.CrossRefPubMedGoogle Scholar
  52. 52.
    Benchimol EI, Turner D, Mann EH, Thomas KE, Gomes T, McLernon RA, et al. Toxic megacolon in children with inflammatory bowel disease: clinical and radiographic characteristics. Am J Gastroenterol. 2008;103(6):1524–31.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Elizabeth C. Maxwell
    • 1
    Email author
  • Peter Mattei
    • 2
  • Andrew B. Grossman
    • 1
  1. 1.Division of Gastroenterology, Hepatology, and NutritionThe Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.Division of General, Thoracic and Fetal SurgeryThe Children’s Hospital of PhladelphiaPhiladelphiaUSA

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