Mesenteric Abscess in Crohn's Disease
A 44-year-old woman with a history of Crohn's disease presented with a 1-week history of progressive abdominal distention, nausea, and feculent vomiting and reported having lost 13.6 kg during the preceding 6 months. She had undergone ileocecostomy 20 years earlier and had been treated with infliximab for 10 years before the current presentation. On presentation, the patient was afebrile and normotensive. An abdominal examination revealed normal bowel sounds and infraumbilical tenderness, without rebound. Laboratory tests showed a normal leukocyte count, but the erythrocyte sedimentation rate and the level of C-reactive protein were elevated, at 67 mm per hour and 121 mg per liter, respectively. Abdominal radiographs showed gaseous distention of multiple small bowel loops (Panels A and B, yellow arrows) and a larger air collection in the middle-to-lower abdomen, where a long air–fluid level (red arrows) could be seen on upright images. Computed tomographic enterography was performed to further investigate these findings and revealed a mesenteric abscess measuring 9 cm by 10 cm by 18 cm that was filled with air and fluid (Panel C, red arrow) and was displacing small bowel loops (yellow arrow). The patient underwent percutaneous drainage and was given antibiotics intravenously and ultimately underwent complete proctocolectomy with end ileostomy. After surgery, biologic therapy was reinitiated, with good clinical results.