Initially, this blog entry was titled “What is the best way to manage an intra-abdominal abscess in pediatric Crohn’s disease?” My answer was simple: it depends on who you ask (Inflamm Bowel Dis 2013; 818-25). As I thought about this study, the responses reminded me of “Family Feud” minus Richard Dawson.
This survey examined the responses of NASPGHAN members. Of the initial 1608 emails which were delivered, 248 fully completed surveys. 25% of respondents were in practice for >20 years and 26% treated >50 patients with Crohn’s disease (CD). 87% of respondents were from U.S.
- What is the best way to image initially? 52% recommended CT scan, 26% MRI, and 21% ultrasound.
- What is the best modality for followup imaging? 47% ultrasound, 33% MRI, and 13% CT
- Antibiotics or drainage for abscess <2 cm? 61% recommended antibiotics; 51% would treat for 3-4 weeks, whereas 19% for 1-2 weeks.
- Antibiotics or drainage for abscess >2 cm? 28% would attempt antibiotics alone
- When is surgery indicated? 75% said only in select cases after completing antibiotics and interventional radiology drainage.
- Anti-TNFα therapy? The survey also questioned the shortest preoperative interval one would prescribe anti-TNFα therapy. The results ranged from 12% for <1 week to 45% who would not give anti-TNFα therapy at all.
The authors note that there is “a paucity of research and practice guidelines for the optimal management of children with intra-abdominal abscess.” There were no trends in management identified based on practitioner level of experience. Some answers to the questions are alluded to by the authors but not expressed definitively. For example, “several studies have reported a lack of association between infliximab and an increased rate of postoperative complications.” “Most infections that occur while on anti-TNFα therapy tend to be opportunistic, not bacterial.”
The study’s conclusions are limited by the low participation rate. In addition, when physicians are confronted with a specific situation, their response in practice may be different than in a theoretical scenario. However, it appears that the answers to these important questions are closer to guesses on a game show rather than best care. More research and collaboration is needed to reduce this highly variable care and determine the most effective approach.
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