Spotting perforations in intestines

[Christine-Radosevich]

   My daughter was diagnosed with Crohn's disease following surgery for suspected appendicitis. The drain that was put after the first surgery caused a hole to develop in the wall of the small intestines. A second surgery was done to clean out the contents that leaked into the abdominal cavity. This hole has still not closed up
  (5 days after surgery) and any water or clear liquid she ingests leaks out of the existing drain. A berium X-ray was done to try and find where the leak is, however, this proved inconclusive. She is going in for a CT scan this afternoon. Is this the most effective imaging to find the leak? If not, what is?
______________
Dear Christine,
The scenario of your daughter's medical course is difficult to interpret based on the information that you provide.  According to what you describe, I am assuming that when the surgeons went in to operate for what they thought was an acute appendicitis, they found an abscess (collection of pus, or infection) that required drainage, and hence the drain left after surgery.  The "hole" you describe occurring after the first surgery can be interpreted in several different ways.  It is unlikely that the drain actually caused the " hole". Morelikely, there was a small perforation that could not be seen at the time of the initial surgery because of all the inflammation.  A small perforation or leak of the bowel could have been present the entire time.  However, you describe another drain placed after the second surgery.  Was part of her small intestines removed?  Was drainage after the second surgery still necessary, and why?
Crohn's disease can cause several different complications.  In Crohn's disease, inflammation involves the entire wall of the bowel.  As a result, sometimes the outside of the bowel wall can adhere to adjacent structures and form a communication, called a fistula.  A fistula can develop between loops of adjacent bowel, between bowel and bladder or even bowel and skin.  Sometimes, fistula require surgical correction, but in many cases conservative, medical management is sufficient.  An abscess, a collection of pus or infection can also develop as a result of the inflammation extending through the bowel wall and into the abdominal cavity.  An abscess always requires drainage, either surgically or locally (a needle drainage through the skin).  An obstruction of the bowel lumen or opening can also occur, either from inflammation or from scar tissue.  Again, often times, a partial obstruction can be managed conservatively with bowel rest (nothing to eat or drink) or with medications, but in severe cases require surgery.  
You mention an inconclusive barium x-ray.  Where was the barium introduced or injected--through the drain, the mouth, or the rectum?  Regardless, the barium x-ray did not answer the question : where is the leak?  The next reasonable step would be a CT scan of the abdomen.  A CT scan is a special x-ray that defines structures in the abdomen using contrast material injected into the vein and taken orally and sometimes rectally.  A CT scan can answer important questions.  For example, a CT scan can detect a collection of fluid in the abdomen that may need drainage; it can detect "free air" or a collection of air outside the lumen of the bowel that would suggest a perforation or hole in the bowel wall; it can show the degree of inflammation of the bowel wall; and it can detect fistula or communications described earlier.  Sometimes the most important "test" is time.  Time allows the inflammation to improve, usually with the help of medications (i.e. steroids, antibiotics, etc.).
This information is provided for informational purposes only and should not be considered a formal medical consultation.  Always consult your physician for specific medical questions.
HFHSM.D.-rf
*keywords: Crohn's Disease, appendicitis
0.4