S4897 Crohn's in Crisis: A Multi-Modal Approach to Abscess Management

Introduction: Crohn’s disease (CD) is a chronic inflammatory disorder marked by transmural inflammation and skip lesions, often resulting in complications such as strictures, fistulas, and abscesses. Intra-abdominal or perianal abscesses complicate management, requiring a balance between infection control and inflammation control. ACG guidelines recommend prioritizing infection management and delaying biologics during active abscesses. However, limited guidance exists for managing non-drainable abscesses in patients with worsening symptoms. We report a case of CD complicated by a non-drainable intra-abdominal abscess in which biologic therapy was initiated due to disease progression. Case Description/Methods: A 27-year-old man with CD (diagnosed 2017) and prior small bowel perforations requiring ileostomy and reversal (2018) presented with 3 weeks of worsening abdominal pain, nausea, and vomiting. He was hospitalized 1 week prior for a 2.9 cm mesenteric abscess, which was managed conservatively due to its location. Upon re-presentation, he could not tolerate oral antibiotics, with worsening symptoms but no fever or GI bleeding. Labs showed leukocytosis, thrombocytosis, and elevated erythrocyte sedimentation rate/C-reactive protein. Repeat CT revealed interval growth of the abscess (now 4.1 cm), thickened ileal loops, and a new nonobstructive portal vein thrombus resulting from his pro-inflammatory state. IR again deferred drainage; surgery recommended non-operative management. He was started on IV piperacillin-tazobactam and therapeutic heparin. By day 6, CT showed a reduction in abscess size. Given a CDAI of 256.9, infliximab was initiated on day 7 without complications. He was discharged on IV antibiotics and started on mercaptopurine and apixaban. At follow-up, he reported mild abdominal pain without recurrence of his initial symptoms and continued to tolerate infliximab therapy. Discussion: We present a case of a patient with moderate to severe CD who underwent biologic therapy induction in the setting of a non-drainable intra-abdominal abscess, with improvement in CD symptoms. Despite current guidelines advising resolution of abscesses prior to starting biologics, initiating anti-tumor necrosis factor therapy during ongoing symptoms was effective in mitigating disease burden. Existing literature evaluating the concurrent usage of anti-tumor necrosis factor and antibiotic therapy suggests that this may be a safe and effective strategy, and future studies are warranted to further investigate these findings so that guidelines may be adjusted accordingly.