Editing Crohn's disease (section)

=== Perforation and abscess ===

* Perforations can occur anywhere in GIT - secondary to either penetrating ulcer or upstream from a stricture
** Caecal perforation occurs in setting of LBO secondary to colonic stricture - needs subtotal colectomy with end ileostomy
** Focal perf secondary to segmental disease - needs either segmental resection and primary anastomosis or Hartmann's. Can be associated with a fibrosing stricture, which may need resection.
* Free perforation and generalised peritonitis
** Uncommon (more common to have a fistula to another viscera, or contained abscess)
** Resect the segment of involved bowel, with a primary anastomosis if there is minimal contamination, and an ostomy if generalised peritonitis is present or the patient has compromised immune system or nutrition (reverse in 4-6 weeks)
* Abscesses are especially common in caecum/ileum secondary to micro-perforation - can be intraperitoneal, extraperitoneal, or intra-mesenteric
** Initial management
*** Antibiotics - ciprofloxacin and metronidazole first-line
*** Percutaneous drainage if possible (step up to surgical drainage if not)
**** Well-defined abscesses <3cm may be treated medically
*** Stop/reduce steroids and immunomodulators (involve gastro)
*** Optimise nutrition for planned resection - TPN vs EEN
*** Wait 3-5 days for improvement
**** >90% of cases improve with drainage, others require elective bowel resection (better outcome if you can get them through to elective procedure in a clean field)
** Subsequent management:
*** Either semi-elective resection of the involved segment in 5-7 days (classical approach) or medical treatment with immunomodulators
**