Background: Although penetrating complications are common in Crohn's disease (CD), little is known about the disease course and operative risk after diagnosis of small bowel penetrating CD complications.
The aim is to study the disease course and need for surgery in patients presenting with penetrating ileal CD.
Methods: In this cohort study, all cross-sectional imaging exams (CT and/or MRI) performed between 2006 and 2014 in patients with CD in a tertiary referral centre were reviewed for the presence of ileal penetrating complications (defined as abscesses, phlegmons or fistula). Demographic, clinical, biochemical, radiological and endoscopic factors were retrospectively assessed in these patients as well as the need for surgery (intestinal resections and/or strictureplasties) and postoperative complications.
Results: In total, we identified 1803 cross-sectional imaging exams in 957 CD patients. In 113 patients penetrating ileal CD complications were identified. The vast majority of these patients were sent to surgery (86%) over time. The median time to surgery was 1 month. Based on univariate analysis, the presence of abscesses (p=0.003) and increased C-reactive protein >22mg/L (based on ROC curve analysis with AUC of 0.723) at documentation of the penetrating complication (p=0.015), were significantly associated with subsequent surgery. The post-operative course was complicated in 14% of patients. Surgery within one month after first documentation of penetrating disease (p=0.004) and previous CD related surgery (p=0.01) were significantly associated with postoperative complications. The presence of prestenotic dilation on imaging resulted in less postoperative complications (p=0.02). Previous therapy (corticosteroids, immunomodulators, anti-TNF alpha therapy) had no impact on the complication rate.
Conclusions: The vast majority of patients with penetrating ileal CD were sent to surgery over time. Abscesses and high inflammatory burden are the most important factors driving the multidisciplinary decision for surgery. Early surgery within one month after documentation of the penetrating CD manifestation was more likely to be associated with a complicated post-operative course, especially anastomotic leakage.