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Diagnostic and treatment approach to abscesses, leaks and fistulae in Crohn’s
HELIOS Kliniken GmbH
Klaus Mönkemüller
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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)
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Current methods to diagnose fistulae, leaks, abscesses and perforations
- Ultrasound and endoscopic ultrasound
- Computer tomography
- Magnetic resonance imaging
1.
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HELIOS Kliniken
Transabdominal ultrasound
aktiver Schub RemissionPower doppler
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HELIOS Kliniken
Ileocolonic edema and stenosis
colon
ileum
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HELIOS Kliniken
Transabdominal ultrasound
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HELIOS Kliniken
Stenoses
entzündliche Engstelle bei M. Crohn
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HELIOS Kliniken
Stenosis with proximal dilation
kompletter Dünndarmverschluß bei M. Crohn
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HELIOS Kliniken
Fistula with abscess collection behind urinary bladder
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HELIOS Kliniken
Liver abscess (complex, multiloculated collection)
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HELIOS Kliniken 11
Crohn’s with inter-enteric fistula
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HELIOS Kliniken
Fistel vom Dünndarm ausgehend
Fistula, Crohn‘s disease
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HELIOS Kliniken 13
Crohn’s with fistula to bladder
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HELIOS Kliniken
Magnetic resonance imaging
Great specificity and sensitivity, 94 and 96%, respectively!
Gourtsoyannis et al. RG 2002
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HELIOS Kliniken
MRT-small bowel
Excellent for fistula and abscessesGourtsoyannis et al. RG 2002
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HELIOS KlinikenGourtsoyannis et al. RG 2002
Excellent for fistula and abscesses
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HELIOS Kliniken
MRT-Sellink
Gute Spezifität und Sensitivität
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HELIOS Kliniken
Transperineal endoscopic ultrasound
• 84.9% Sensitivity for perianal abscesses and 85% for fistulae
Maconi G et al. Am J Gastroenterol 2007
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HELIOS Kliniken 19
Normal sphincterFistula
Healed fistula
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HELIOS Kliniken 20
MRT vs EUS for perirectal fistulae
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Therapy
- Radiologic
- Surgery
- Endoscopy
2.
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HELIOS Kliniken 22
Crohn’s with abscess
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HELIOS Kliniken
Psoas abscess
Percutaneous drainage, try to use large bore catheters
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HELIOS Kliniken
56 year old female with history of CD for 15 yrs
Surgical resection: best option to heal fistula and abscess
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HELIOS Kliniken 25
Is there a role for endoscopic dilation for the therapy of abscess and fistula?
Bo Shen, Cleveland Clinic, USA
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HELIOS Kliniken 26
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HELIOS Kliniken 27Bo Shen, Cleveland Clinic, USA
Do not dilate if fistula is < 5 cm from stricture!
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HELIOS KlinikenGutierrez et al. Am J Gastroenterol 2006
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HELIOS Kliniken
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HELIOS Kliniken
Fistulae: 37% vs 40%
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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
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HELIOS Kliniken
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HELIOS Kliniken
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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
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Fistulae3.
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HELIOS Kliniken
Perianal fistula in Crohn‘s disease
Hellers G et al. Gut 1980
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HELIOS Kliniken 37
Precise analysis and description of intra- and extraluminal structuresis mandatory when evaluating peri-anal fistulae
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HELIOS Kliniken 38
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HELIOS Kliniken
„Perianal disease activity index“ (PDAI)
Irvine EJ J Clin Gastro 1995
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HELIOS Kliniken 40
Orientation during lower GI endoscopy
Red dot posteriorGreen arrow anterior, vaginal fistulaPhoto B Patient lying on back
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HELIOS Kliniken 41Bo Shen, Cleveland Clinic, USA
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HELIOS Kliniken 42
Fibrin glue injection
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HELIOS Kliniken 43
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HELIOS Kliniken
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HELIOS Kliniken 45
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HELIOS Kliniken 46
Endoscopic needle knife sinusotomy, conversion to „diverticulum
Bo Shen, Cleveland Clinic, USA
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HELIOS Kliniken
Case
• 53-year old female patient
• Severe left sided diverticulitis with abscess
• Underwent hemicolectomy with colo-rectal anastomosis
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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
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HELIOS Kliniken
Endoscopy: large anastomotic dehiscence and perforation
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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
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HELIOS Kliniken
Over-the-scope (Ovesco) Clip
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HELIOS Kliniken
• Closure of dehiscence of anastomosis (leak) using three over-the-scope clips
Endoscopic approach (2)
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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)
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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)
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HELIOS Kliniken
Sponge
GIE 2010
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HELIOS KlinikenLoske, G. Hamburg, Germany 56
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HELIOS KlinikenVorstellung HELIOS Kliniken 57
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Conclusions• Fistulae and abscesses are a
complex problem in Crohn’s disease
• Team of GI, endoscopist, radiologyand surgery is essential to treat thesecomplications