Variations in management of intra-abdominal abscesses in children
with Crohn’s disease
SURVEY:
Survey instructions:
This Web-based survey has been designed for physician members of NASPGHAN/APSA to
explore the individual practice variations among pediatric gastroenterologists and pediatric
surgeons for the management of intra-abdominal abscesses in children with Crohn’s disease.
This survey will assess how intra-abdominal abscesses are approached in regards to imaging
modalities, drainage, antibiotic use, medical therapy, surgical intervention, and feeding/nutritional
management.
Please complete the survey based on how you, personally, manage these patients and not based
on your group or institution’s management approach. We do acknowledge that management of a
patient with intra-abdominal abscess(es) is complex and can involve consultation with radiology
and surgery. We do ask, however, that you chose your answer based on your best clinical
judgment. The survey will take just 5-10 minutes to complete. Please choose one response per
question unless otherwise noted.
We appreciate your participation in this survey.
The following questions are about imaging studies:
A 14 year old patient with known Crohn’s disease presents with fever, abdominal pain,
diarrhea, fatigue and fullness in the right lower quadrant. You suspect an intra-abdominal
abscess.
Based on this clinical scenario, indicate the imaging modality you are most likely to use
Please select only 1 response per question
1. If the patient presents during regular business hours, which of the following imaging
modalities do you prefer as an initial choice?
( ) CT
( ) MRI
( ) Ultrasound
2. Which of the following imaging modalities would you use to reassess (follow-up) the
abscess (assume non-urgent need, regular business hours)?
( ) CT
( ) MRI
( ) Ultrasound
( ) I do not routinely repeat imaging to reassess the abscess
The following questions are about abscess drainage:
3. Is interventional radiology (IR) available at your institution?
( ) Yes
( ) No, IR drainage is not available at my institution. (SKIP to question #9)
Assuming that imaging revealed a single intra-abdominal abscess in the right lower
quadrant, respond to the questions below.
4. If the abscess is of sufficient size and in a location such that interventional radiology (IR)
feels they can drain it, would you recommend drainage of the abscess by IR?
( ) Yes, for any abscess described in this question
( ) Yes, but only for a larger abscess (e.g. greater than 2cm)
( ) No, I prefer to try to treat any abscess with antibiotics initially and only ask for drainage if
unsuccessful
( ) No, I prefer immediate surgical drainage and resection
5. If drainage by IR is performed, do you typically:
( ) Perform aspiration only
( ) Perform both aspiration and leave a drain in place
6. Do you routinely have IR inject the abscess cavity with contrast material to determine if
a fistula is present prior to removal of the drain?
( ) Yes
( ) No
Your patient’s abscess was injected with contrast material to determine whether or not
there was a demonstrable fistula to the abscess cavity.
7. What would you recommend as the next step in management if a fistula was
demonstrated?
( ) Immediate surgical resection
( ) Medical therapy alone without a plan for surgical resection
( ) Medical therapy with a plan for surgical resection
8. What would you recommend as the next step in management if a fistula was not
demonstrated?
( ) Immediate surgical resection
( ) Medical therapy alone without a plan for surgical resection
( ) Medical therapy with a plan for surgical resection
9. Would demonstration of a fistula during contrast injection of the abscess cavity influence
the nutritional plan you would prescribe?
( ) Yes
( ) Yes, but only if it is a large fistula
( ) No (SKIP to question # 11)
The following questions are about feeding and nutrition:
10. If a fistula is demonstrated during contrast injection of the abscess cavity and there is
no evidence of obstruction, what nutrition plan would be implemented?
( ) NPO
( ) NPO and start parenteral nutrition
( ) Clear liquid diet only
( ) Full-liquid diet only
( ) Soft diet
( ) Low residue, regular diet
( ) Regular diet
11. What factors would prompt you to make your patient NPO? Please select all that
apply.
( ) High output drain (when a drain is present)
( ) Any drainage (when a drain is present)
( ) Febrile
( ) Size of the abscess
( ) Degree of abdominal pain
( ) Degree of abdominal tenderness on examination
( ) Ill or toxic appearing
( ) Unstable vital signs (hypotension or tachycardia)
The following questions are about antibiotic therapy:
Assume that one of your patients has a right lower quadrant abscess that was identified on
imaging. The radiologist feels it would be amendable to percutaneous drainage, however
you decide to treat your patient using medical therapy with no plan for surgical resection.
12. What is the maximum size of an abscess you would treat with antibiotics (without drain
placement by IR or surgical resection)?
( ) <1 cm
( ) 1-2 cm
( ) 3-4
( ) >5 cm
( ) None of the above. I always have a drain placed if the abscess is accessible to percutaneous
IR drainage.
13. If you are not planning IR drainage or a surgical resection, how many weeks do you
typically treat with antibiotics?
( ) < 1 week
( ) 1-2 weeks
( ) 3-4 weeks
( ) 5-6 weeks
( ) >6 weeks
( ) Not applicable. I always have a drain placed if the abscess is accessible to percutaneous
drainage
One of your patients has a right lower quadrant abscess that was identified on imaging.
You decide to treat with surgical resection after antibiotic therapy and IR drainage. Your
patient is responding to antibiotic therapy.
14. How many weeks would you treat the patient with antibiotics prior to surgery?
( ) < 1 week
( ) 1-2 weeks
( ) 3-4 weeks
( ) 5-6 weeks
( ) >6 weeks
Suppose you chose to prescribe anti-TNFα therapy (infliximab, adalimumab, or
certolizumab). Please select only ONE response per question regarding when you would
initiate therapy given the following scenarios.
15. Antibiotics have been initiated, the abscess was successfully drained by IR, and no plan
for surgical resection.
( ) Immediately
( ) After 1-2 weeks of antibiotics
( ) After 3-4 weeks of antibiotics
( ) After 4 or more weeks of antibiotics
16. Antibiotics have been initiated, the abscess was successfully drained by IR, and interval
surgical resection is planned.
( ) Immediately
( ) After 1-2 weeks of antibiotics
( ) After 3-4 weeks of antibiotics
( ) After 4 or more weeks of antibiotics
( ) Only after surgical resection
17. Assuming antibiotics have been initiated, the abscess was successfully drained by IR,
and interval surgical resection is planned, what is the shortest interval pre-operatively you
would give anti-TNFα therapy?
( ) <1 week pre-operatively
( ) 1-2 weeks pre-operatively
( ) 3-4 weeks pre-operatively
( ) >4 weeks pre-operatively
( ) I would not give anti-TNFα therapy pre-operatively
18. Antibiotics have been initiated, the abscess was successfully drained by IR, and
uncomplicated surgical resection has been completed.
( ) Immediately
( ) 1-2 weeks post-operatively
( ) 3-4 weeks post-operatively
( ) 4 or more weeks post-operatively
( ) Not until evidence of recurrence
The following questions about surgical resection:
19. Which of the following reflects your most common surgical approach in patients with
intra-abdominal abscesses?
( ) Immediate surgical resection
( ) Surgical resection after completing a course of antibiotics
( ) Surgical resection after completing a course of antibiotics and IR drainage, then proceed with
surgical resection in only select cases
( ) Surgical resection after completing a course of antibiotics and IR drainage
20. In a patient with intra-abdominal abscess due to Crohn’s disease, which of the following
would be an absolute indication for surgical resection? (select all that apply)
( ) Fistula to adjacent small bowel
( ) Fistula to large bowel
( ) Fistula to bladder, vagina, or other organ
( ) High grade bowel obstruction
( ) Multiple abscesses (>1 abscess cavity)
( ) Ipsilateral hydronephrosis or other signs of ureteric obstruction
( ) Proximal bowel dilatation
( ) Other (please explain)
21. What is your profession?
( ) Pediatric Gastroenterologist (includes fellows in training)
( ) Pediatric Surgeon (includes fellows in training) (SKIP PATTERN HERE #26)
( ) Other (specify)
The following questions are about prevention and treatment:
You have a patient who was just diagnosed with Crohn’s disease with moderate ileocecal
inflammation and found to have a single abscess located in the right lower quadrant,
without evidence of fistula or obstruction. Assume your patient has not received prior
therapy.
For each of the following conditions, which medications are you likely to immediately
prescribe to treat underlying Crohn’s disease and /or prevent reoccurrence of the abscess?
For each row, select ALL that apply.
Antibiotics
Thiopurine
Methotrexate
AntiTNFα
22. Intra-abdominal abscess without IR
drainage and without surgical resection
23. Intra-abdominal abscess with IR drainage
and without surgical resection
24. Intra-abdominal abscess with IR drainage
and planned surgical resection (PREoperatively)
25. Intra-abdominal abscess with IR drainage
and with surgical resection (POSToperatively)
Demographics:
26. Please select the number of patients you, yourself, manage with Crohn’s disease
( ) Zero, I do NOT take care of any patients with Crohn’s disease
( ) <10
( ) 10-50
( ) >50
27. What is your gender?
( ) Male
( ) Female
28. Please select the number of years you have been in practice as a pediatric
gastroenterologist or a pediatric surgeon?
( ) Still in fellowship training
( ) <5 years
( ) 5-10 years
( ) 11-20years
( ) >20 years
Corticosteroids
29. In which country do you practice?
( ) United States
( ) Canada (SKIP to question #31)
( ) Mexico (SKIP to question #32)
( ) Other (SKIP to question #32)
30. In which region do you primarily practice? (select one)
( ) Northeast (MD, PA, NY, NJ, DE, CT, MA, VT, RI, NH, ME)
( ) Southeast (AR, LA, MS, AL, GA, FL, SC, NC, VA, WV, KY, TN)
( ) Southwest (TX, NM, AZ, OK)
( ) Midwest (MN, WI, MI, IN, OH, IL, IA, MO, KS, NE, SD, ND)
( ) West (MT, WY, CO, UT, NV, ID, CA, OR, WA, HI, AK)
31. In which province/territory do you primarily practice?
( ) Alberta
( ) British Columbia
( ) Manitoba
( ) New Brunswick
( ) Newfoundland and Labrador
( ) Nova Scotia
( ) Ontario
( ) Prince Edward Island
( ) Quebec
( ) Saskatchewan
( ) Northwest Territories
( ) Nunavut
( ) Yukon
32. How would you describe your primary practice? (select one)
( ) University/Academic center
( ) Hospital or clinic
( ) Community/Private practice based
( ) HMO
( ) Government
( ) Other
33. How many physicians are in your group? (select one)
( ) Solo practice
( ) 2-5
( ) 6-10
( ) 11-20
( ) >20
Thank you for your participation in this survey!