From the Guidelines
Management of a terminal ileum abscess typically requires a dual approach of antibiotics and drainage, followed by evaluation for inflammatory bowel disease (IBD). Initially, broad-spectrum antibiotics such as piperacillin-tazobactam 4.5g IV every 8 hours or a combination of ciprofloxacin 500mg twice daily and metronidazole 500mg three times daily should be started immediately, as suggested by 1. For abscesses larger than 3cm, percutaneous drainage guided by CT or ultrasound is recommended, with success rates varying from 74 to 100% 1. Smaller abscesses may resolve with antibiotics alone, as suggested by Feagins et al. 1, who found that non-drainable abscesses smaller than 3 cm and without evidence of fistula and no steroid therapy are likely to respond to antibiotic therapy alone.
Evaluation for IBD
Once the acute infection is controlled, typically after 10-14 days of antibiotics, evaluation for underlying IBD should be performed. This includes:
- Colonoscopy with ileoscopy and biopsies
- Fecal calprotectin measurement
- Serological markers like ASCA and p-ANCA MR enterography is preferred over CT for detailed small bowel imaging to minimize radiation exposure, as recommended by 1.
Imaging Studies
According to 1, cross-sectional imaging (computed tomography, magnetic resonance imaging, ultrasonography) is recommended to detect strictures and extra-luminal IBD complications including fistulae and abscesses. Contrast-enhanced computed tomography is the key study in the emergency setting in assessing IBD extra-luminal complications such as abscesses and fistulae, and a source of bleeding in the case of gastro-intestinal haemorrhage.
Maintenance Therapy
If Crohn's disease is confirmed, maintenance therapy with immunomodulators like azathioprine (2-2.5mg/kg/day) or biologics such as adalimumab (initial dose 160mg, then 80mg at week 2, followed by 40mg every other week) should be considered to prevent recurrence. Surgery may be necessary for abscesses that don't respond to medical management or drainage, or for complications like fistulas or strictures. Close follow-up is essential as terminal ileum abscesses often indicate underlying Crohn's disease, which requires long-term management.
From the Research
Management of Terminal Ileum Abscess
- The management of terminal ileum abscess requires a comprehensive approach, including clinical, laboratory, endoscopic, and histopathological evaluation to determine the underlying cause of the inflammation 2.
- Intra-abdominal infections, such as terminal ileum abscess, can be managed with antimicrobial therapy, source control, and supportive care 3, 4.
- The choice of antimicrobial agent and duration of therapy depend on the severity of the infection, the presence of underlying conditions, and the results of microbiological cultures 3, 4.
Evaluation for Possible IBD
- Terminal ileitis can be a manifestation of inflammatory bowel disease (IBD), such as Crohn's disease, and requires evaluation for possible IBD 2.
- The use of antibiotics, such as metronidazole or ciprofloxacin, may be beneficial in the management of IBD, particularly in the treatment of Crohn's disease and pouchitis 5.
- However, the evidence for the use of antibiotics in IBD is limited, and further studies are needed to determine their efficacy and optimal duration of therapy 5.
- A thorough evaluation, including endoscopy, histology, and imaging studies, is necessary to establish a diagnosis of IBD and to guide treatment decisions 2.