Diagnostic and treatment approach to abscesses, leaks and fistulae in Crohn’s

HELIOS Kliniken GmbH

Klaus Mönkemüller

HELIOS Kliniken

Abscesses, fistulae in Crohn‘s disease

aktiver Schub Remission

• 10-15%• Fistulae:

• enterocutaneous,• interenteric, • entero-organic (liver, gyn tract)• perianal

• Abscesses: • simple, • complex (multiloculated, difficult location)

Current methods to diagnose fistulae, leaks, abscesses and perforations

- Ultrasound and endoscopic ultrasound

- Computer tomography

- Magnetic resonance imaging

1.

HELIOS Kliniken

Transabdominal ultrasound

aktiver Schub RemissionPower doppler

HELIOS Kliniken

Ileocolonic edema and stenosis

colon

ileum

HELIOS Kliniken

Transabdominal ultrasound

HELIOS Kliniken

Stenoses

entzündliche Engstelle bei M. Crohn

HELIOS Kliniken

Stenosis with proximal dilation

kompletter Dünndarmverschluß bei M. Crohn

HELIOS Kliniken

Fistula with abscess collection behind urinary bladder

HELIOS Kliniken

Liver abscess (complex, multiloculated collection)

HELIOS Kliniken 11

Crohn’s with inter-enteric fistula

HELIOS Kliniken

Fistel vom Dünndarm ausgehend

Fistula, Crohn‘s disease

HELIOS Kliniken 13

Crohn’s with fistula to bladder

HELIOS Kliniken

Magnetic resonance imaging

Great specificity and sensitivity, 94 and 96%, respectively!

Gourtsoyannis et al. RG 2002

HELIOS Kliniken

MRT-small bowel

Excellent for fistula and abscessesGourtsoyannis et al. RG 2002

HELIOS KlinikenGourtsoyannis et al. RG 2002

Excellent for fistula and abscesses

HELIOS Kliniken

MRT-Sellink

Gute Spezifität und Sensitivität

HELIOS Kliniken

Transperineal endoscopic ultrasound

• 84.9% Sensitivity for perianal abscesses and 85% for fistulae

Maconi G et al. Am J Gastroenterol 2007

HELIOS Kliniken 19

Normal sphincterFistula

Healed fistula

HELIOS Kliniken 20

MRT vs EUS for perirectal fistulae

Therapy

- Radiologic

- Surgery

- Endoscopy

2.

HELIOS Kliniken 22

Crohn’s with abscess

HELIOS Kliniken

Psoas abscess

Percutaneous drainage, try to use large bore catheters

HELIOS Kliniken

56 year old female with history of CD for 15 yrs

Surgical resection: best option to heal fistula and abscess

HELIOS Kliniken 25

Is there a role for endoscopic dilation for the therapy of abscess and fistula?

Bo Shen, Cleveland Clinic, USA

HELIOS Kliniken 26

HELIOS Kliniken 27Bo Shen, Cleveland Clinic, USA

Do not dilate if fistula is < 5 cm from stricture!

HELIOS KlinikenGutierrez et al. Am J Gastroenterol 2006

HELIOS Kliniken

HELIOS Kliniken

Fistulae: 37% vs 40%

HELIOS Kliniken

Drainage versus surgery for abscesses

51 Pt., 10 years, follow-up: 3,8 yrs

Garcia et al. J Clin Gastroenterol 2001

Op: 33Percutaneous Drainage 6Antibiotics 10

0

10

20

30

40

50

60

70

Recurrence

OpPercutaneousAntibiotics

HELIOS Kliniken

HELIOS Kliniken

HELIOS Kliniken

Algorithm for the therapy of abscess in Crohn‘s disease

Abdominal Abscess

Large lumen or complex fistula

OPPercutaneous Drainage

success recurrence

- +

Antibiotics for all patients

Follow-up

AZA for all patients

if fistula: biologicals

Fistulae3.

HELIOS Kliniken

Perianal fistula in Crohn‘s disease

Hellers G et al. Gut 1980 

HELIOS Kliniken 37

Precise analysis and description of intra- and extraluminal structuresis mandatory when evaluating peri-anal fistulae

HELIOS Kliniken 38

HELIOS Kliniken

„Perianal disease activity index“ (PDAI)

Irvine EJ J Clin Gastro 1995

HELIOS Kliniken 40

Orientation during lower GI endoscopy

Red dot posteriorGreen arrow anterior, vaginal fistulaPhoto B Patient lying on back

HELIOS Kliniken 41Bo Shen, Cleveland Clinic, USA

HELIOS Kliniken 42

Fibrin glue injection

HELIOS Kliniken 43

HELIOS Kliniken

HELIOS Kliniken 45

HELIOS Kliniken 46

Endoscopic needle knife sinusotomy, conversion to „diverticulum

Bo Shen, Cleveland Clinic, USA

HELIOS Kliniken

Case

• 53-year old female patient

• Severe left sided diverticulitis with abscess

• Underwent hemicolectomy with colo-rectal anastomosis

HELIOS Kliniken

• Five days post-operatively was found to have a leak of the

anastomosis with abscess and free air

• Leucocytosis: 18,000

• An external (percutaneous) drain was placed to drain the pus

HELIOS Kliniken

Endoscopy: large anastomotic dehiscence and perforation

HELIOS Kliniken

Endoscopic approach (1)

• Lavage of colo-rectum

• Lavage of anastomotic leak with 1 liter saline

• Placement of two tubes into ileum and cecum bridging the leak

HELIOS Kliniken

Over-the-scope (Ovesco) Clip

HELIOS Kliniken

• Closure of dehiscence of anastomosis (leak) using three over-the-scope clips

Endoscopic approach (2)

HELIOS Kliniken

• Overtube-assisted insertion of endo-sponge (Vac)• The sponge was sutured to a nasogastric tube and inserted into the rectum

using a US Endoscopy esophageal overtube

Endoscopic approach (3)

HELIOS Kliniken

• Removal of endosponge on day 7• Removal of bridging tubes on day 9, with endoscopic

evidence of fistula closure and healing• Patient is doing well six months later

Endoscopic approach (4)

HELIOS Kliniken

Sponge

GIE 2010

HELIOS KlinikenLoske, G. Hamburg, Germany 56

HELIOS KlinikenVorstellung HELIOS Kliniken 57

Conclusions• Fistulae and abscesses are a

complex problem in Crohn’s disease

• Team of GI, endoscopist, radiologyand surgery is essential to treat thesecomplications