NOT ALL THE PERIANAL ABSCESSES CAN BE DRAINED: MEDICAL MANAGEMENT AND FOLLOW UP
Raguraj Chandradevan*, Subbaramiah Sridhar, Humberto Sifuentes
Augusta University Medical College of Georgia, Augusta, GA
Perianal manifestations of Crohn's disease include perianal fistula, perianal abscess and anal canal lesions. If the perianal abscess is associated with a perianal fistula, medical management (anti-TNF agent) for fistulizing Crohn's disease is started after the local infection is controlled and the abscess has been drained to control fistula healing. In some circumstances drainage is difficult due to location and the size of the abscess and medical management is needed with antibiotics. Patients need monitoring of the abscess by radiological or endoscopic interventions. We outlined three presentations here with successful outcome.
Patient A was a 29 y/o F came with 1 month of bloody diarrhea. CT abdomen/pelvis revealed pan peri colonic inflammation and left sided perirectal abscess with the size of 1.1*1.9*4.8 cm. Flexible sigmoidoscope revealed deep ulcers in sigmoid colon and two fistula tracts arouse proximal to dentate line. She was tachycardic and febrile. She underwent EUA and no discrete abscess or fistula tract was noted. She received metronidazole and ciprofloxacin and in 1-week flexible sigmoidoscope was repeated. Fistula tracts became fibrotic and healing mucosa noted. She was discharged and started on Infliximab.
Patient B was a 48 y/o F with history of Crohn's disease for 28 years (A2/L3/B3P), history of perianal abscess, s/p subtotal colectomy with ileocolonic anastomosis received adalimumab and currently off for few years presented with diarrhea and rectal pain. CT abdomen pelvis revealed inflammation of ileum and reminding colon and two abscesses. One abscess was in cul-de-sac (1.6*2.4cm) and other one was right ischiorectal fossa (2.9*1.6cm). Patient was started on ciprofloxacin and metronidazole and due to the location and size of the abscess, colorectal surgery and IR deemed unable to drain. In 1 week, patient was scheduled for an EUS guided drainage for both abscesses as they were around 3cm from the bowel lumen after having a look at the rectum with flexible sigmoidoscope to make sure there were no active inflammation. During examination, both abscesses regressed, and size was noted to be 1.1 cm and 1.3 cm. medical therapy was continued and patient followed up as outpatient and started on adalimumab.
Patient C was a 54 y/o M with PMH of Crohn's disease (A3/L3/B3P) s/p total colectomy with ileorectal anastomosis, with history of perianal fistula and abscess presented with 1 week history of rectal pain. He was on ustekinumab and CT abdomen pelvis revealed no abscess however during examination, noted a pustular drainage at 3' clock position. He was started on ciprofloxacin and metronidazole and had an MRI pelvis which revealed inter sphincteric fistula with 0.9*0.7cm abscess. He was followed as outpatient. No surgical intervention done and in 2 weeks fistular drainage stopped and continued ustekinumab.
Patient A: Left: Initial CT appearance of the abscess. Right: Initial endoscopic appearance of the abscess on the top and healing fistula in the bottom.
Patient B: Initial CT appearance of the image (A). followed by endoscopic (B) and EUS view of the abscess (C).
Patient C: MRI image of abscess (D).
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