Abdominal Abscess and Near-Stricture

Hello all,

This is my first post on the site. I have found some very helpful information on here. I am currently looking for some advice:

I was diagnosed with Crohn's in 2007, but did not begin receiving treatment until earlier this year when my symptoms worsened. I went on a high dose of prednisone followed by Humira. After two months on the Humira and a slow tapering of the prednisone I began to notice an area of hardness in my lower abdomen and bloating above this. There was almost no pain, but both the bloated area and the hard region grew over several days and led me to seek medical attention.

I was hospitalized for about a week during which time the doctors determined that I had an abscess that could not be drained because there was not enough space between it and the abdominal wall? I was put on TPN for nutrition and IV cipro and flagyl for most of my stay. A CT scan revealed that the affected area of my intestine (near my cecum) was swollen almost to the point of stricture. Upon discharge the plan was to continue on TPN for 12 hours a day, take oral cipro and flagyl as well as clear liquids and come back for a follow-up CT in about 2 weeks.

Based on the results of the follow-up CT the surgeon wanted to do a resection surgery in 2-3 weeks. He showed me the CT revealing the narrowness of the opening in my intestine (near the cecum). He indicated that some of the fluid marker would disappear when passing through this area (indicating fistula/ae).

I decided to seek a second opinion and began treatment with a family friend who is a GI surgeon and his co-worker, a GI doctor. These doctors decided to keep me on the TPN and oral cipro/flagyl and continue to wait in order to rest my bowel and hopefully avoid a resection surgery.

During my time out of the hospital I introduced full liquids and started trying to get back on solids as per my doctor's advice. However, my lower abdomen started to bloat again and I began experiencing fever symptoms. I went back to the ER and was hospitalized. They did a CT scan which indicated that the abscess had grown since the last CT. They continued the TPN and put me on IV invanz for antibiotic. As of discharge the plan has been to continue the invanz at home through my PICC line, do my first entyvio infusion (which was done a couple days ago) and continue TPN and clear liquids. The only real follow-up I have is in two weeks for my next entyvio infusion.

I apologize for the novel. My question is that it is my understanding that antibiotics alone will not clear up an abscess. The infectious disease doctor at the hospital said as much. He wanted to drain the abscess. My doctors wanted to wait because of some concern of the Crohn's spreading? I'm really unsure as to the point of waiting another two weeks. I guess they want to try the entyvio to see if the fistula/ae close in order to avoid a re-section surgery. I am quite confused and overwhelmed. My preliminary research indicates that entyvio isn't even all that effective for Crohn's. If I truly need a re-section and we're just stalling I'd rather just have the surgery and not have to spend these weeks waiting and hooking up to a TPN bag. I've thought about seeking out a GI doctor who is a Crohn's specialist for a now third opinion. Aside from that, any thoughts/advice regarding the abscess and the re-section surgery would be greatly appreciated.

Thank you very much for your time in reading this,

Mike

Hi Mike and welcome to the forum.

I am so sorry to hear that you have found yourself in this situation.

From what I have read I see the following issues:

• If the abscess is contained then without draining antibiotics won’t penetrate the area and therefore it won’t heal.
• Is the fistula connected to the abscess? If it is then without draining it and keeping the drain in it will continue to be fed from the bowel and will persist or reform.
• In the past it has been recognised that whilst the biologics are very good at healing fistulae in the perianal region they do not have the same success for intra-abdominal fistulae that emanate in the ileum. As far as I am aware this remains the case but that is not to say that biologics haven’t been successful for some.

My son had a resection 4 years ago due to the same complications you are currently experiencing. He had a fistula and abscess that the doctors were aware of and another fistula and abscess that they were unaware of until they actually operated. That is just something to bear in mind, imaging is a very useful tool but it can only the tell the doctors so much and the true picture of what is going on sometimes isn’t apparent until the surgeon ‘gets in there’.

My own feeling is that surgery would likely be the best option for you.

Dusty. xxx

Mike,
I am kind of in a similar situation. I went to the ER in the beginning of June d/t abdominal pain. They diagnosed me with an acute flare of my Crohn's. They put me on massive doses of prednisone, pentasa and azathioprine. While the inflammation has decreased, my pain has not. After a second colonoscopy it showed that my stricture had gotten even worse. We contemplated Humira, but that can make strictures worse and ultimately lead to surgery anyway. I meet with a surgeon on Weds to hopefully schedule a resection. We've been trying things and nothing has been working to decrease my pain for 2 months now. At this point I am very ready to have surgery and just get this stricture out of me. I tried to avoid it for a while--everyone always says to avoid surgery--but it just became obvious that it was the best option for me. I don't think a third opinion from a Crohn's specialist would hurt. Just try to be open to the idea that surgery may be whats best for you, and if it is, that's okay.

Good luck and keep us posted.

Dusty,

Thank you for your support. I hope that your kids are doing well.

-I do not know if the abscess is contained. I'll be calling my GI doctor tomorrow.
-I am pretty positive that the abscess is connected to a fistula. I will confirm this tomorrow.
-Very good to know that biologics are not all that effective in healing intra-abdominal fistulae.

Prior to deciding on surgery, did your son's doctors attempt delay/avoidance methods similar to those that I have experienced?

Did the surgery involve re-sectioning the intestine AND clearing out the abscess or did they drain the abscess and do the re-section separately?

I've been feeling for the past week or so like surgery might be the only way to move on and eventually begin to re-establish my life. If that is the case, I'd like to just go ahead with it.

Thank you very much for your help. I wish Matt and Sarah well.

Mike

Prior to deciding on surgery, did your son's doctors attempt delay/avoidance methods similar to those that I have experienced?

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Matt developed complications very quickly following diagnosis so options became very limited. They did hope that IV steroids and antibiotics would help the situation, which they did, but once it was apparent that there was a fistula it made the move to surgery inevitable. It was at this time that I asked about biologics and the fact that he had an established infection ruled biologics out. It was also at this time that they spoke about the difficulty in healing fistulae that originate in the small bowel. Again, that is not to say that medication doesn’t heal them for some but rather they just don’t have the level of success at resolving them as they do elsewhere. He was in hospital for quite a lengthy time and being over the new year period it is a time of year when the consultants each take a week off and so cover for each other. Because of this he did see four different specialist colorectal surgeons and two Crohn’s specialists and they were all of the same opinion. Certainly makes decisions easier when everyone is of the same opinion!

Did the surgery involve re-sectioning the intestine AND clearing out the abscess or did they drain the abscess and do the re-section separately?

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He had the abscess, it was on the psoas muscle, drained when he was in hospital. They left the drain called a pigtail in and a few days later did a sinogram. This involved injecting die into the drain to see if it tracked back to the bowel. It did so this confirmed that there was a fistula connected to it. Because of this the drain was left in until he had his surgery 3 months later. This is where it becomes complicated and highlights the limitations of imaging in some circumstances. When he was diagnosed he had 100mm of affected bowel in the terminal ileum. When he started to flare imaging indicated that the inflammation had spread significantly throughout his small bowel, this is what the docs were naturally working off and why they delayed surgery, they wanted to wait until the acute inflammation became chronic and so give him the best possible outcome with his surgery. As it was when they opened him up what they were actually seeing on the scan was another abscess called a phlegmon, it is a type of abscess that is more flat and diffuse and it had adhered to his abdominal wall. On the scan it gave the impression of inflamed bowel. This abscess was removed during surgery and it turned out that the amount of actual bowel inflammation at diagnosis had not changed. His original abscess had remained drained and reduced in size due to the drain so for that it was simply a case of removing the drain during surgery.

TPN was also tossed around as part of his treatment plan both to rest the bowel and to try and build him up a bit but it never came into being as he did eventually respond to treatment whilst in hospital. If he hadn’t responded then they would have had no choice but to do surgery there and then regardless of infection and inflammation and that is where the TPN would have come into the equation.

I hope this makes sense!

Thank you for your kind wishes.

Dusty. xxx

This is my first time posting anything. I don't have all the medical terms down of what I went through, but I had ulcerative colitis and then they diagnosed me with Crohns, which led to a perirectal abscess that I had to have emergency surgery on to get it drained. I have hold next to the anus that is about a dime size that has not healed. It has been 18 months and it still drains. I am super depressed and not sure if it is ever going to heal. Does anyone know if this is normal or if it will heal or any suggestions?

@aguarisco, can you find out from your doctor if you have a fistula? If you have a fistula it will continually drain specially if you have an infection down there.