Dr. Konijeti details a multidisciplinary approach to intraabdominal abscesses.
So next talk with Dr Corey Cometary who directs the diabetes clinic. It's cribs and one of the course directors. We have this little flip because glory is going to be talking about conservative or medical management of obstruction. Um And intra abdominal abscesses when dealing with these patients with acute documents. Thank you. Thank you for that. Nice introduction. And uh yeah I'm happy to talk about intra abdominal abscesses and battle obstructions. Um Certainly complications that we've seen the setting of inflammatory bowel disease and certainly something that we work with our colleagues closely on. So these are my disclosures but I really probably my greatest disclosure are my colleagues and their input on this lecture. So let's start with intra abdominal abscesses. Um as you've heard today penetrating complication of princess disease. Some patients even have a penetrating phenotype. It can affect up to 20% of patients over their lifetime with risk factors including tobacco use and essentially anything that indicates a high disease severity. So prior abscess or surgery or active file inflammation. It's something to suspect when patients present with a fever, acute abdominal pain and abdominal mask and diagnosis is often by cT scan with I. V. Contrast in the emergency room. Um Typical labs here are helpful to order along with the substance evaluation. Now it's important to recognize that abscesses may initially present as a flagman and this is really an area of acute localized inflammation unbounded and undrinkable and here on the right you can see pictures of a patient who presented to the hospital with intra abdominal flight plans. However these can progress to an abscess and so classically that's where we have a walled off puss filled collection. That would be amenable to drainage. So with management you really want to take a multidisciplinary approach and I've outlined sort of the big three ways to approach abscesses. So first you want to treat the infection with antibiotics with or without drainage. So essentially if you have a flagman or small abscess less than three cm antibiotics may be sufficient. Have abscesses more than three centimeters or you have a small one that's persisting or progressing. That's for drainage really helps Now surgery may be needed initially. As you've just heard from dr warsi if patients present with signs of peritonitis or a complicated abscess and associated obstruction. A large fistula, well or medically refractory IBD. The second thing to approach is their Crohn's disease. So not only do you need to treat the acute complication but also figure out how you're going to manage the Crohn's. And this is we're really looking back to see what their clinical course has been. It is really helpful. What medications have they tried have they had prior surgery and at the same time access the current extent and severity of the Crohn's as well as potential options whether surgery or medical management. Initially it's helpful to tear. Put on steroids and hold immune suppression really in the setting of an acute septic complication and as director Metro mentioned DVT prophylaxis and then getting cross sectional imaging with entering graffiti is especially helpful to assess inflammation structuring especially distal to the abscess in any signs of fistula from a nutritional standpoint. Initially we often keep these patients and pio with fluids. It's very helpful to consult your dietitian and the reason we do this is not just because of sepsis but also possibly needing surgery. If you anticipate that the patient will be able to tolerate pio and take within a couple of days you can keep them MPO and on goods and then reassess. However often these patients are malnourished on admission or they may need a little bit more time and P. O. And this is where preferable potential nutrition can help as a bridge for a few days but typically we do not use this for more than a week and then if they are unable to tolerate oral intake they prolonged MPO status or you anticipate surgery. TPM can be helpful. Okay So when antibiotics alone are used for a flagman or small abscess you'll want to assess the clinical response over the next 2-3 days and if they respond transition them to oral antibiotics, discharge them with a plan to re image and then start or optimize their therapy. However if they don't respond then essentially you want to re image with an entire biography. Reassess your approach and then start with drainage. So when it comes to drainage. Pretty Tania's drainage is preferred and has this discuss excuse me. Success rate of over 70%. This is done by IR image guided and trends. Abdominal er transfer utility. The abscess train is typically left in and the output is usually low either prevalent or sarah singleness However the output is high. Uh Don't worry. Surgery is on board but this fistula and typically that indicates a fistula but that may also decrease now with abscess drainage as well as prince treatment. However oftentimes these patients do end up needing surgery. Um surgical drainage of the abscess itself like dr Warsi mentioned is pursuit of perpetrating a strange isn't feasible or fails to control the sepsis. And essentially you want to send any output for culture and adjust antibiotics is needed towards the sensitivities After abscesses or drainage. I find it helpful to get an obsessive ground about 2-3 days later. And really this is what I'm looking to see if the cavity is shrinking. If they have any signs of official er Luminal connection when they're improved it's okay to advance their diet to clears advance slowly and monitor the output and again discharge on antibiotics with the planned for IBD management if they're not improving or worsening. Then again you get into the cycle where you're reassessing and re imaging and this is both for the abscess and for the Crohn's. But this is where I find it's helpful to put patients on belarus. Total potential nutrition and then really consider where you're going with therapy or surgery when it comes to medical therapy I found with treating these patients that waiting is not always an option even when they're hospitalized. However there is limited data for starting therapy in the setting and it's helpful to discuss you're sort of plan of attack with your surgeons and with your team before starting if you're planning on starting therapy. Certainly biologics are preferred over steroids and TNS in the setting have the most data for penetrating disease and do not appear to increase the risk of intra abdominal abscesses as dr Singh mentioned intra abdominal abscesses developing the setting of early TNF use are more likely a hallmark of active disease than the therapy itself. And then you want to monitor their response over the next few days. Now if they improve an artist charged you can start biologics as an outpatient within a few weeks if you didn't already started inpatient home health is very helpful to help with drain management teaching patients how to flush their dream. And some patients may or may not need I. V. Antibiotics and that can be helpful as well But otherwise you'll continue oral antibiotics or essentially for weeks until resolution of the abscess. I find that that can take anywhere from 2 to 4 weeks to happen And generally every 1-2 weeks. I'm repeating an obsessive Graham as long as the output is low uh will pull the drain. However the output persists. That's where we're getting serial imaging and really discussing with surgery which way to go, especially if medical therapy isn't working. Um just remember that the risk of a recurrent abscess is high and patients may need drainage and that does not always indicate a failure of medical therapy. As John mentioned, surgery is sometimes needed for patients within two abdominal abscesses. I think what I'll highlight here is from the medical perspective, it's helpful to treat the abscess with antibiotics and for catania's drainage for even a week. Usually while the patients are on TPM prior to surgery, the goal here being that you want to reduce local Subsys improve their new traditional status to really improve their postoperative outcomes If patients are tolerating oral intake and still need surgery. There is recent data suggesting that pre operative central nutrition for 2-4 weeks can even further improve their postoperative outcomes. So I'd be interested to hear what my colleagues think about that during the discussion. So now let's talk about bowel obstructions. Um again, can be caused by transmittal inflammation, penetrating complications. Like we just discussed fibrous geonosis, but also non inflammatory issues like adhesions and this can affect up to 50% of patients with crowns over their lifetime, much like all these other complications, you want to adjust their address their course, whether they've had prior surgery and what their current status is with respect to therapy in symptoms. Now for a cute small bowel obstructions, patients are highly symptomatic with obstructive symptoms. Pain observation. They may be hypovolemic your septic depending on how long has this been going on and classically their exam has distention. Tympani, high pitched tinkling sounds. If they're hypoactive you may worry a little bit more about ischemia or even alias labs and imaging are often done. But for a patient with crowns presenting with obstruction. A CT scan again is often done but it does help to identify the inflamed segments as well as signs of any complications. Okay so how do you approach this while taking a multidisciplinary approach again is very important. Um In addition to keeping them MPO and on fluids it's important to stay ahead of their electrolyte abnormalities. Do dVt prophylaxis? If there are any signs of perforation or ischemia, these patients are often going straight to surgery If they have abscesses antibiotics and drainage as we discussed and may need surgery. Typically this is where we try to avoid steroids. However, if it really does look like inflammation is driving this process then I. V. Steroids are going to be the initial approach to therapy for symptomatic management of patients are obstructed or have persistent nemesis even in the setting of a partial obstruction then bell decompression with an N. G. Tube to low intermittent section is very helpful if they have malnutrition and weight loss or they just can't tolerate pio and take even with treatment then early parental nutrition is helpful including as a potential bridge to surgery. Now, as much as we try to avoid opiates. Um In IBD in general i in this setting we tried to judiciously use them of the obstruction is really bad. Um This can also help with symptoms, right? So for acute S. POS you'll start I. V. Steroids and then look for response in 2 to 3 days and if they respond and they're able to tolerate pOS I think it's helpful to really get a handle on their disease activity. So this may involve repeat imaging. It may not depending on the quality of the initial scan but again looking at inflammation structuring, priest zoonotic dilation which may indicate chronic structuring and complications. You can do a colonoscopy during the hospitalization for nick uspto once they clinically improved and are tolerating morals and this may also potentially be an opportunity for dilation. If relevant for treatment really, you're going to start medical therapy. Again, limited data in the acute setting but TNS have the most data compared to others. No matter what route you go. It's important to also optimise or escalate therapy is needed. And then again you want to try come up with approaches to the structural process whether balloon dilation or surgical approaches. Now sometimes we have patients who have chronic partial s poso chronic SPS by definition are partial and this is typically due to fix segment of bell whether structure or adhesions symptoms may be chronic but much more low grade, including an exam. However, these patients are at risk for an acute sp oh, and evaluation is just about the same with labs and imaging. However, here, while you're planning on treating the inflammation and fibrosis diagnosis, I find that treatment is a lot more centered around the fibrous geonosis and this is where it's really important to have a discussion with the patient about surgery, especially if you look at that picture to your right. She has a big large segment of chronically dilated small bell that might be nonfunctional. Whether or not dilation would actually improve for symptoms is unclear, especially given that problematic dilation With endoscopic balloon dilation, you just want to make sure that these structures are accessible by endoscopy typically less than five cm and not associated with penetrating complications. From a technical standpoint. As a gastroenterologist, you can dilate these strictures about 2-3 mm beyond the point of resistance Hold at various intervals. And what you're looking for after dilation is that mucosal break. This has a high success rate of over 70%, but up to 70% of patients may need repeat violations within 3-5, 3- 24 months. The results are generally comparable on large meta analysis for primary as well as the nasty Matic strictures with or without the presence of inflammation. Generally, I quote, a rate of complications for endoscopic balloon dilation is 2.8%, so 2-3% based on guidelines right now. In traditional injection of corticosteroids and biologics offer no clear benefit for the prevention of repeat balloon dilation or surgery. It's not currently recommended. But I think you need to think about this on a case by case basis. I will add that newer endoscopic techniques um like strict keratotomy and stent placement are being explored as possible options as well. And this is my final slide on surgical management. We've had a wonderful surgical talks already. Uh so for the gastro neurologist and other providers out there the times to consider surgery or when you see priest fanatic dilation. Um and studies have suggested that small bell Luminal dilation of more than three cm is pretty indicative of chronic structuring that might not improve with dilation. Long strictures, multiple strictures, ones that are inaccessible regulated associated with penetrating complications. Certainly feel your medical therapy and balloon dilation. But it's also important to consider patient related factors. How is this patient doing? Would they really benefit from medical therapy or maybe with surgery be helpful solution to sort of reset the clock. Now we've heard a lot about structure plasticine segmental resection today. So I won't go into those, but for the provider, it's important, no matter what route you choose to have a plan for IBD management. Post op whether to treat residual disease, prevent recurrence or monitor for postoperative recurrence. So that's all I have. Thank you for your time
