Review article: investigation and management of internal fistulae in Crohn’s disease

Abstract

SummaryBackgroundCrohn’s disease is an inflammatory, penetrating intestinal disease associated with fistula formation. Fistulae in Crohn’s disease can be classified into external and internal fistulae. Internal fistulae form between the gastrointestinal tract and another internal organ and include enteroenteric, enterocolic, enterovesical and rectovaginal fistulae. They are associated with significant morbidity and a decreased quality of life.AimTo review the classification, diagnosis, medical and surgical management of internal fistulae in Crohn’s disease, and propose a treatment algorithm.MethodsA literature review on internal fistulae in Crohn’s disease in the adult population was undertaken, synthesised and summarised.ResultsInternal fistulae occur in up to 15% of patients with Crohn’s disease. Multi‐modal assessment including a combination of endoscopy and cross‐sectional imaging, usually magnetic resonance, is required to diagnose fistulae and determine extent of disease. Determining optimal treatment strategies for these complex fistulae remains a challenge due to limited and generally low‐quality data. Most studies to date have focussed on luminal disease, with (usually post hoc) outcomes more often reported for external fistulae, particularly perianal fistulae, than internal fistulae. Anti‐tumour necrosis factor therapies have emerged as the mainstay of medical therapy, with particularly promising data for enterovesical fistulae, but many patients will still require surgical intervention. The indications and optimal timing of surgery vs medical therapy remains uncertain; thus multi‐disciplinary input when making such decisions is important.ConclusionsInternal fistulae result in significantly increased morbidity in Crohn’s disease, and further studies to determine optimal multi‐modality management strategies incorporating medical and surgical therapy are required.

Long-Term Outcomes of Biological Therapy in Crohn's Disease Complicated With Internal Fistulizing Disease: BIOSCOPE Study From GETECCU

“…Whether these results might be obtained in penetrating disease is still to be demonstrated, and the chronic and potentially irreversible nature of these lesions could play against it (7,17). Nevertheless, no The American Journal of GASTROENTEROLOGY randomized placebo-controlled trial has directly evaluated the efficacy of biologic agents when stricturing or penetrating disease has already developed (6). In addition, surgical management should be also discussed with these patients, including aspects such as the risk of postoperative recurrence, the need for prophylactic therapy, and even further surgical interventions (18).…”

“…In addition, surgical management should be also discussed with these patients, including aspects such as the risk of postoperative recurrence, the need for prophylactic therapy, and even further surgical interventions (18). Previous studies evaluating different types of fistulas and outcomes showed that anti-TNF agents may be effective in this setting (6,18), although this has been mostly in small case series and only in the short term (8,(19)(20)(21)(22)(23). In a cohort of 93 patients with penetrating disease (77% entero-enteric or entero-colonic, 17% entero-vesical, and 5% entero-vaginal), 27% of patients achieved fistula closure after 5 years of follow-up, and 47% required surgery (10).…”

“…Evidence with vedolizumab or ustekinumab for internal fistulizing disease is also limited (6). In the pivotal trials of ustekinumab UNITI-1 and -2, 14% and 10% of patients had a history of an abdominal abscess, respectively (25).…”

“…Previous studies evaluating different types of fistulas and outcomes showed that anti-TNF agents may be effective in this setting (6,18), although this has been mostly in small case series and only in the short term (8,19–23). In a cohort of 93 patients with penetrating disease (77% entero-enteric or entero-colonic, 17% entero-vesical, and 5% entero-vaginal), 27% of patients achieved fistula closure after 5 years of follow-up, and 47% required surgery (10).…”

“…The availability of biologic agents, and especially tumor necrosis factor (TNF)-α inhibitors, has led to overall better disease control. However, evidence on their efficacy in penetrating CD is still limited (6). Anti–TNF-α are possibly the most effective drugs in this scenario, but data supporting its use are still insufficient (7).…”