The CT shows a 10 cm narrowed, thickened, and enhancing segment of ileum with proximal dilation and with an adjacent complex fluid collection measuring up to 6.5 cm in diameter which is in communication with two discrete points along the inflamed segment, suggestive of penetrating Crohn’s disease with intra-abdominal abscess.
What are your next steps in management? (select all that apply)
IV antibiotics
Great choice! Antibiotics are definitely indicated as part of the management of intra-abdominal abscess.
Interventional radiology for CT-guided drainage
Excellent! The location of this abscess appears amenable to CT-guided drainage. If possible, this is an important step, as if the patient requires surgery, primary anastomosis may be attempted if the abscess has been fully drained. If the collection was not resolved, diverting ileostomy would be recommended as part of surgical management.
Immediate surgery
Not yet. Though surgery may ultimately be required as part of this patient’s management, antibiotics and percutaneous drainage should be performed first as these interventions would improve surgical outcome. There is no absolute indication for immediate surgery, such as a frank perforation with intra-abdominal free air, at this time.
Colonoscopy
This patient is presenting with an intra-abdominal abscess and suspected new diagnosis of Crohn’s disease. He has never had a colonoscopy before, and this should be performed to determine the extent of disease. While frank perforation would be a contraindication to colonoscopy (and an indication for immediate surgery), the presence of intra-abdominal abscess is not.
Start biologic therapy for Crohn’s
While a trial of biologic therapy can be considered, the presence of a stricture with pre-stenotic dilation is a strong indication that this patient will be better served with limited ileal resection once the acute infection has been cooled down with antibiotics and drainage.
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