Multidisciplinary and evidence-based management of fistulizing perianal Crohn’s disease

Abstract

Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.

MR Imaging of Perianal Crohn Disease

“…A recent systematic review of the literature revealed a pooled closure rate of about 55% in CD patients by using anal fistula plug (80). Others have reported fistula healing rates between 38% and 71%, but with high rates of recurrence of 50%-70% (12). Most studies looking at the success of the anal fistula plug in the management of CD are limited by heterogeneous patient populations, variable technical expertise, and short follow-up, making conclusions about its efficacy circumspect.…”

“…Anti-TNF biologic therapy.-The cell signaling protein TNF mediates and promotes inflammation in CD and is time of diagnosis and are indicated in the setting of pelvic sepsis. Clinical healing rates using metronidazole have been reported between 0% and 56%, but symptoms recur in the large majority of patients at cessation of therapy (12). Despite widespread use of antibiotics, a placebo controlled pilot trial of 25 CD patients with actively draining perianal fistulas failed to demonstrate a therapeutic advantage of either metronidazole or ciprofloxacin over placebo (65).…”

“…The two components react together to form a fibrin clot that acts as a sealant. Perianal fistula healing rates of 38%-85% have been reported in small retrospective studies but with high recurrence rates, particularly in CD patients (12,74,79) or those with complex fistulas (79).…”

“…It is not known why some patients with CD develop perianal disease, generally a more aggressive phenotype, while others do not. Genetic, microbiologic, and immunologic factors are thought to play a role (7,(10)(11)(12). The presence of perianal fistulas at initial CD presentation appears to be a risk factor for "disabling" CD (ie, steroid dependence or refractoriness, need for immunosuppressive therapy, hospitalization, surgical resections, and/or chronic and disabling symptoms) (13) and for the need for subsequent surgery (14).…”

Indian Society of Gastroenterology consensus statements on Crohn’s disease in India

“…Remission is defined as absence of fistula drainage despite gentle finger compression, with closure of all fistulae that were draining at baseline for at least 2 consecutive visits 4 weeks apart. Disease activity elsewhere in the GI tract provides some evidence as to overall disease activity and may guide treatment [124,125].…”