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Gu B, Venkatesh K, Williams AJ, Ng W, Corte C, Gholamrezaei A, Ghaly S, Xuan W, Paramsothy S, Connor S. Higher infliximab and adalimumab trough levels are associated with fistula healing in patients with fistulising perianal Crohn’s disease. World J Gastroenterol 2022; 28:2597-2608. [PMID: 35949350 PMCID: PMC9254145 DOI: 10.3748/wjg.v28.i23.2597] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/21/2021] [Accepted: 05/07/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tumor necrosis factor-alpha inhibitors, including infliximab and adalimumab, are effective medical treatments for perianal fistulising Crohn’s disease (CD), but not all patients achieve fistula healing.
AIM To determine the correlation between perianal fistula healing and closure with infliximab and adalimumab trough levels.
METHODS In this multicentre retrospective study conducted across four tertiary inflammatory bowel disease centres in Australia, we identified CD patients with perianal fistulae on maintenance infliximab or adalimumab who had a trough level within twelve weeks of clinical assessment. Data collected included demographics, serum infliximab and adalimumab trough levels (mg/L) within 12 wk before or after their most recent clinical assessment and concomitant medical or surgical therapy. The primary outcome was fistula healing, defined as cessation in fistula drainage. The secondary outcome was fistula closure, defined as healing and closure of all external fistula openings. Differences between patients who did or did not achieve fistula healing were compared using the chi-square test, t test or Mann-Whitney U test.
RESULTS One hundred and fourteen patients (66 infliximab, 48 adalimumab) were included. Forty-eight (72.7%) patients on maintenance infliximab achieved fistula healing and 18 (27.3%) achieved fistula closure. Thirty-seven (77%) patients on maintenance adalimumab achieved fistula healing and 17 (35.4%) achieved fistula closure. Patients who achieved fistula healing had significantly higher infliximab and adalimumab trough levels than patients who did not [infliximab: 6.4 (3.8-9.5) vs 3.0 (0.3-6.2) mg/L, P = 0.003; adalimumab: 9.2 (6.5-12.0) vs 5.4 (2.5-8.3) mg/L, P = 0.004]. For patients on infliximab, fistula healing was associated with lower rates of detectable anti-infliximab antibodies and younger age. For patients on adalimumab, fistula healing was associated with higher rates of combination therapy with an immunomodulator. Serum trough levels for patients with and without fistula closure were not significantly different for infliximab [6.9 (4.3-10.2) vs 5.5 (2.5-8.3) mg/L, P = 0.105] or adalimumab [10.0 (6.6-12.0) vs 7.8 (4.2-10.0) mg/L, P = 0.083].
CONCLUSION Higher maintenance infliximab and adalimumab trough levels are associated with perianal fistula healing in CD.
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Affiliation(s)
- Bonita Gu
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, New South Wales, Australia
| | - Kavya Venkatesh
- Department of Medicine, University of Newcastle, Newcastle 2308, New South Wales, Australia
| | - Astrid-Jane Williams
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
| | - Watson Ng
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
| | - Crispin Corte
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, New South Wales, Australia
- Central Clinical School, University of Sydney, Sydney 2050, New South Wales, Australia
| | - Ali Gholamrezaei
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Sydney 2170, New South Wales, Australia
| | - Simon Ghaly
- Department of Gastroenterology, St Vincent’s Hospital Sydney, Sydney 2010, New South Wales, Australia
- St Vincent’s Clinical School, University of New South Wales, Sydney 2010, New South Wales, Australia
| | - Wei Xuan
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Sydney 2170, New South Wales, Australia
| | - Sudarshan Paramsothy
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney 2139, New South Wales, Australia
- Concord Clinical School, University of Sydney, Sydney 2139, New South Wales, Australia
| | - Susan Connor
- South Western Sydney Clinical School, University of New South Wales, Sydney 2170, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney 2170, New South Wales, Australia
- Ingham Institute of Applied Medical Research, Sydney 2170, New South Wales, Australia
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Abstract
PURPOSE OF REVIEW Multiple new medications with novel mechanisms of action are now available to treat Crohn's disease (CD). However, they have varying effectiveness in the management of perianal CD. Identifying the most appropriate therapy and optimizing it is essential to maximize effectiveness of therapy. Additionally, the management of perianal CD requires imaging of the perianal area to identify the fistula anatomy and local complications such as abscesses that require surgical drainage. Initial surgical assessment is key to drain abscesses and allow fistula healing with medical therapy. RECENT FINDINGS Although anti-tumor necrosis factor (TNFs) remain the most effective medications to treat perianal CD, real-world data suggests that ustekinumab may be a 2nd-line option in patients nonresponsive to an anti-TNF or having contraindications. Mesenchymal stem cells are an emerging therapeutic approach that is currently in Phase 3 trials in the United States and poised to play a major role in the treatment algorithm. SUMMARY The management of perianal CD requires a multidisciplinary approach with a combination of initial imaging and surgical assessment to adequately control local sepsis, optimization of biological therapy with adjunct antibiotics or immunomodulators, and close clinical follow-up with imaging to evaluate response to therapy and guide further surgical management options.
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Gu B, De Gregorio M, Pipicella JL, Vande Casteele N, Andrews JM, Begun J, Connell W, D'Souza B, Gholamrezaei A, Hart A, Liew D, Radford-Smith G, Rimola J, Sutherland T, Toong C, Woods R, Wu Y, Xuan W, Williams AJ, Ng W, Ding NS, Connor S. Prospective randomised controlled trial of adults with perianal fistulising Crohn's disease and optimised therapeutic infliximab levels: PROACTIVE trial study protocol. BMJ Open 2021; 11:e043921. [PMID: 34210720 PMCID: PMC8252869 DOI: 10.1136/bmjopen-2020-043921] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Perianal fistulising Crohn's disease (pfCD) can be somewhat treatment refractory. Higher infliximab trough levels (TLIs) may improve fistula healing rates; however, it remains unclear whether escalating infliximab therapy to meet higher TLI targets using proactive, or routine, therapeutic drug monitoring (TDM) improves outcomes. This randomised controlled trial aimed to assess whether infliximab therapy targeting higher TLIs guided by proactive TDM improves outcomes compared with standard therapy. METHODS AND ANALYSIS Patients with active pfCD will be randomised 1:1 to either the proactive TDM arm or standard dosing arm and followed up for 54 weeks. Patients in the proactive TDM arm will have infliximab dosing optimised to target higher TLIs. The targets will be TLI ≥ 25 µg/mL at week 2, ≥ 20 µg/mL at week 6 and ≥ 10 µg/mL during maintenance therapy. The primary objective will be fistula healing at week 32. Secondary objectives will include fistula healing, fistula closure, radiological fistula healing, patient-reported outcomes and economic costs up to 54 weeks. Patients in the standard dosing arm will receive conventional infliximab dosing not guided by TLIs (5 mg/kg at weeks 0, 2 and 6, and 5 mg/kg 8 weekly thereafter). Patients aged 18-80 years with pfCD with single or multiple externally draining complex perianal fistulas who are relatively naïve to infliximab treatment will be included. Patients with diverting ileostomies or colostomies and pregnant or breast feeding will be excluded. Fifty-eight patients per arm will be required to detect a 25% difference in the primary outcome measure, with 138 patients needed to account for an estimated 6.1% primary non-response rate and 10% dropout rate. ETHICS AND DISSEMINATION Results will be presented in peer-reviewed journals and international conferences. Ethics approval has been granted by the South Western Sydney Local Health District Human Research Ethics Committee in Australia. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12621000023853); Pre-results.
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Affiliation(s)
- Bonita Gu
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Michael De Gregorio
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Joseph Louis Pipicella
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Niels Vande Casteele
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jane M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jakob Begun
- Immunity, Infection, and Inflammation Program, Mater Research Institute, Brisbane, Queensland, Australia
- Department of Gastroenterology, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - William Connell
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Basil D'Souza
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Ali Gholamrezaei
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ailsa Hart
- Inflammatory Bowel Diseases Unit, St Mark's Hospital, Harrow, UK
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Graham Radford-Smith
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jordi Rimola
- Inflammatory Bowel Disease Unit, Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Tom Sutherland
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Medical Imaging Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Catherine Toong
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Immunology, NSW Health Pathology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Rodney Woods
- Department of Colorectal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Yang Wu
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Wei Xuan
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Biostatistics Unit, The Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Astrid-Jane Williams
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Watson Ng
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Nik Sheng Ding
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Gastroenterology and Hepatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Susan Connor
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH.
| | - Jean H Ashburn
- Department of Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC
| | - Mantaj S Brar
- Department of Surgery, Mount Sinai Hospital, Toronto, ON; Zane Cohen Center for Digestive Diseases, Toronto, ON; Department of Surgery, University of Toronto, ON
| | - Michele Carvello
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | | | - Anthony de Buck van Overstraeten
- Department of Surgery, Mount Sinai Hospital, Toronto, ON; Zane Cohen Center for Digestive Diseases, Toronto, ON; Department of Surgery, University of Toronto, ON
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Paulo Gustavo Kotze
- IBD Outpatient Clinics, Colorectal Surgery Unit, Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Lillian M Reza
- Fistula research Unit, St Mark's Hospital and academic institute, London, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center, Colon and Rectal Surgery Unit, Italy; Humanitas University, Department of Biomedical Sciences, Italy
| | - Scott A Strong
- Department of Gastrointestinal Surgery, Northwestern University, Chicago, IL
| | - Philip J Tozer
- Fistula research Unit, St Mark's Hospital and academic institute, London, UK
| | - Adam Truong
- Department of Surgery, Cedars Sinai, Los Angeles, CA
| | | | - Takayuki Yamamoto
- Inflammatory Bowel Disease Center & Department of Surgery, Yokkaichi Hazu Medical Center, Yokkaichi, Japan
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Wolford DD, Fichera A. Prophylaxis of Crohn's disease recurrence: A surgeon's perspective. Ann Gastroenterol Surg 2020; 4:514-520. [PMID: 33005846 PMCID: PMC7511563 DOI: 10.1002/ags3.12368] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/10/2020] [Accepted: 05/26/2020] [Indexed: 12/23/2022] Open
Abstract
Management of inflammatory bowel disease has evolved extensively in the last three decades. We have learnt a lot about the pathophysiology and natural history of the disease. New effective classes of drugs with the associated potential morbidity have been introduced. New surgical techniques have been popularized leading to a better understanding of the optimal timing of surgery. The result is a very complex subspecialty of gastroenterology and colorectal surgery called the "IBDologist." Only if we manage these complex patients in the context of a multi-disciplinary team will we be able to obtain outstanding outcomes, specifically with high and sustained remission rates for these patients.
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Affiliation(s)
- Dallas D. Wolford
- Division of Colorectal SurgeryDepartment of SurgeryBaylor University Medical CenterDallasTexasUSA
| | - Alessandro Fichera
- Division of Colorectal SurgeryDepartment of SurgeryBaylor University Medical CenterDallasTexasUSA
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Smith R, Hicks D, Tomljanovich PI, Lele SB, Rajput A, Bullard Dunn K. Adenocarcinoma Arising from Chronic Perianal Crohn's Disease: Case Report and Review of the Literature. Am Surg 2020. [DOI: 10.1177/000313480807400113] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Perianal disease is a common manifestation of Crohn's disease. Rarely malignancy arises in perianal fistulas. The etiology of fistula related cancer remains a subject of debate. We present a unique case of a perianal Crohn's disease with adenomatous epithelialization of a fistula tract and an associated mucinous adenocarcinoma. Our case demonstrates that mucinous adenocarcinoma can arise in long standing perianal Crohn's disease and may be associated with adenomatous transformation of the epithelial lining of the fistula tract.
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Affiliation(s)
- Richard Smith
- Departments of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York and the
| | - David Hicks
- Departments of Pathology, Roswell Park Cancer Institute, Buffalo, New York and the
| | - Paul I. Tomljanovich
- Head and Neck/Section of Plastic and Reconstructive Surgery, Roswell Park Cancer Institute, Buffalo, New York and the
| | - Shashikant B. Lele
- Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, New York and the
| | - Ashwani Rajput
- Departments of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York and the
- Department of Surgery, University of Buffalo, SUNY, Buffalo, New York
| | - Kelli Bullard Dunn
- Departments of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York and the
- Department of Surgery, University of Buffalo, SUNY, Buffalo, New York
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7
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Abstract
Perianal Crohn's is a common manifestation of Crohn's disease. Primary manifestations of perianal disease mirror common anorectal conditions, however treatment is less successful than in those patients without Crohn's related perianal disease. A multimodal approach to therapy including medical and surgical modalities is often necessary. The goal of treatment is to manage symptoms while maintaining continence.
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Affiliation(s)
- Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Fegan 3, 300 Longwood Ave, Boston, MA.
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8
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Mahmoud NN, Halwani Y, Montbrun SD, Shah PM, Hedrick TL, Rashid F, Schwartz DA, Dalal RL, Kamiński JP, Zaghiyan K, Fleshner PR, Weissler JM, Fischer JP. Current management of perianal Crohn’s disease. Curr Probl Surg 2017; 54:262-298. [DOI: 10.1067/j.cpsurg.2017.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 02/04/2017] [Indexed: 12/11/2022]
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Nuij V, Fuhler GM, Edel AJ, Ouwendijk RJT, Rijk MCM, Beukers R, Quispel R, van Tilburg AJP, Tang TJ, Smalbraak H, Bruin KF, Lindenburg F, Peyrin-Biroulet L, van der Woude CJ. Benefit of Earlier Anti-TNF Treatment on IBD Disease Complications? J Crohns Colitis 2015. [PMID: 26223842 DOI: 10.1093/ecco-jcc/jjv130] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anti-tumour necrosis factor [anti-TNF] treatment was demonstrated to have disease-modifying abilities in inflammatory bowel disease [IBD]. In this study, we aimed to determine the effect of anti-TNF treatment timing on IBD disease complications and mucosal healing [MH]. METHODS The following IBD-related complications were tested in relation to timing of anti-TNF therapy start in newly diagnosed IBD patients [n = 413]: fistula formation, abscess formation, extra-intestinal manifestations [EIM], surgery, referral to academic centre, and MH. RESULTS A total of 85 patients [21%] received anti-TNF (66 Crohn's disease [CD], 16 ulcerative colitis [UC], 3 inflammatory bowel disease unclassified [IBDU]) of whom 57% [48 patients] were treated < 16 months after diagnosis. Patients receiving anti-TNF early [< 16 months] did not differ from patients receiving anti-TNF late [> 16 months] regarding gender, age, smoking status, and familial IBD. More importantly, patients receiving anti-TNF early did not suffer less IBD-related complications during follow-up as compared with patients started on anti-TNF late, nor was more MH observed. Similar results were obtained when anti-TNF treated patient were stratified more stringently, ie < 12 months [40 patients] vs >2 4 months [24 patients]. Cox regression analysis showed no beneficial correlations between anti-TNF timing and IBD-related complications. Anti-TNF treated patients achieving MH were 11 times less likely to develop EIMs compared with patients who did not achieved MH while on anti-TNF. CONCLUSIONS This study was unable to confirm a benefit of earlier anti-TNF treatment on IBD disease complications. This could be explained by more aggressive treatment earlier in disease, resulting in fewer IBD complications. However, it seems more likely that inappropriate selection of patients for therapy leads to suboptimal treatment and subsequently suboptimal outcome.
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Affiliation(s)
- Veerle Nuij
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Gwenny M Fuhler
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Annemarie J Edel
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Rob J T Ouwendijk
- Department of Gastroenterology and Hepatology, Ikazia Hospital, Rotterdam, The Netherlands
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Ruud Beukers
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Antonie J P van Tilburg
- Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Thjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Hermen Smalbraak
- Department of Internal Medicine, Lievensberg Hospital, Bergen op Zoom, The Netherlands
| | - Karlien F Bruin
- Department of Gastroenterology and Hepatology, Tweesteden Hospital, Tilburg, The Netherlands
| | - Flordeliz Lindenburg
- Department of Gastroenterology and Hepatology, Franciscus Hospital, Roosendaal, The Netherlands
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Hepatology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-les-Nancy, France
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10
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Smith RK, Carter Paulson E. Perianal fistulas in patients with inflammatory bowel disease. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Impact of perineal Crohn's disease on utilization of care in the absence of modifiable predictors of treatment failure. Int J Colorectal Dis 2014; 29:1535-9. [PMID: 25269618 DOI: 10.1007/s00384-014-2013-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2014] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The burden of perineal Crohn's disease (PCD) remains poorly characterized, and many patients ultimately require fecal diversion or proctectomy. Our goal was to characterize the clinical course of patients presenting with perineal Crohn's disease, focusing on the cohort of patients ultimately requiring fecal diversion, and identify modifiable predictors for this unfortunate outcome. METHODS We performed a retrospective review of 81 consecutive patients who underwent 172 operations to address complications of PCD. Diverted patients were compared to those who did not require diversion in regard to demographics, surgical procedure, postoperative infliximab, and presence of proctitis (chi square, t tests). Logistic regression was utilized to predict the need for fecal diversion. The number of visits needed to undergo care for this condition was quantified. RESULTS Eight-one patients underwent a total of 172 surgical procedures and had a total of 2713 outpatient visits (range 1-118) to address symptoms of perineal Crohn's disease. Following first intervention, only 57.1 % healed at 3 months. These rates were highest in patients treated with fistulotomies and were not impacted by whether patients received postoperative infliximab (p = 0.703). Patients (23.5 %) underwent three or more surgical procedures to control their PCD and ultimately only 60 % healed without diversion, which was performed in 19 (23.5 %) patients. Patients undergoing more than three operations (OR = 10.9, p = 0.006) and women with rectovaginal fistula (OR = 3.88, p < 0.01) were at a high risk for diversion. Modifiable factors such as infliximab, smoking, proctitis, and surgery aimed at closing the internal anal opening did not alter outcome. CONCLUSIONS In the patients with perineal Crohn's, complex fistulas healing rates appear to be independent of postoperative infliximab or procedures aimed at closing the internal anal opening. Those who do not heal require numerous specialist visits.
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12
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Abstract
BACKGROUND Despite potent drugs and surgical techniques, the treatment of perianal fistulizing Crohn's disease (CD) remains challenging. We assessed treatment strategies for perianal fistulizing CD and their effect on remission, response, and relapse. METHODS Patients with perianal fistulizing CD visiting the Erasmus MC between January 1, 1980 and January 1, 2000 were identified. Demographics, fistula characteristics, and received treatments aimed at the outcome of these strategies were noted. RESULTS In total, 232 patients were identified (98 male; 42.2%). Median follow-up was 10.0 years (range, 0.5-37.5 yr). Complex fistulas were present in 78.0%. Medical treatment (antibiotics, steroids, immunosuppressants, and anti-tumor necrosis factor) commenced in 79.7% of the patients and in 53.2%, surgery (colectomy, fistulectomy, stoma, and rectum amputation) was performed. Simple fistulas healed more often than complex fistulas (88.2% versus 64.6%; P < 0.001). Rectum involvement was not associated with a lower remission rate, and anti-tumor necrosis factor therapy did not increase complete fistula healing rates in simple and complex fistula. Initially, healed fistulas recurred in 26.7% in case of simple fistulas and in 41.9% in case of complex fistulas (P = 0.051). Only 37.0% of the complex fistulas were in remission at the end of follow-up compared with 66.7% of the simple fistulas (P < 0.001). CONCLUSIONS Only the minority of CD complex perianal fistulas were in remission after conventional treatment strategies after a median follow-up of 10 years. Simple fistulas were more likely to heal than complex fistulas, and less of these healed fistulas relapsed. However, more than 3 quarters of the patients had complex perianal fistulas.
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13
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Sordo-Mejia R, Gaertner WB. Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease. World J Gastrointest Pathophysiol 2014; 5:239-51. [PMID: 25133026 PMCID: PMC4133523 DOI: 10.4291/wjgp.v5.i3.239] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 05/07/2014] [Accepted: 05/28/2014] [Indexed: 02/06/2023] Open
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.
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Improving the outcome of fistulising Crohn's disease. Best Pract Res Clin Gastroenterol 2014; 28:505-18. [PMID: 24913389 DOI: 10.1016/j.bpg.2014.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/13/2014] [Accepted: 04/13/2014] [Indexed: 01/31/2023]
Abstract
Fistulas are a frequent manifestation of Crohn's disease (CD) and can result in considerable morbidity. Approximately 35% of all patients with CD will experience one fistula episode during their disease course of which 54% is perianal. The major symptoms of patients with perianal fistulas are constant anal pain, the formation of painful swellings around the anus and continuous discharge of pus and/or blood from the external fistula opening. The exact aetiology of perianal fistulas in CD patients remains unclear, but it is thought that a penetrating ulcer in the rectal mucosa caused by active CD forms an abnormal passage between the epithelial lining of the rectum and the perianal skin. Genetic, microbiological and immunological factors seem to play important roles in this process. Although the incidence of perianal fistulas in patients with CD is quite high, an effective treatment is not yet discovered. In this review all available medical and surgical therapies are discussed and new treatment options and research targets will be highlighted.
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Cutaneous manifestations in patients with inflammatory bowel diseases: pathophysiology, clinical features, and therapy. Inflamm Bowel Dis 2014; 20:213-27. [PMID: 24105394 DOI: 10.1097/01.mib.0000436959.62286.f9] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The skin is one of the most common extraintestinal organ system affected in patients with inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis. The skin manifestations associated with IBD are polymorphic and can be classified into 4 categories according to their pathophysiology: (1) specific, (2) reactive, (3) associated, and (4) induced by IBD treatment. Cutaneous manifestations are regarded as specific if they share with IBD the same granulomatous histopathological pattern: perianal or metastatic Crohn's disease (commonly presenting with abscesses, fistulas or hidradenitis suppurativa-like features) is the prototype of this setting. Reactive cutaneous manifestations are different from IBD in the histopathology but have close physiopathological links: pyoderma gangrenosum, a neutrophil-mediated autoinflammatory skin disease typically manifesting as painful ulcers, is the paradigm of this group. Among the cutaneous diseases associated with IBD, the most commonly seen are erythema nodosum, a form of panniculitis most commonly involving bilateral pretibial areas, and psoriasis, a T helper 1/T helper 17-mediated erythematous squamous inflammatory disease. Finally, the number of cutaneous adverse reactions because of IBD therapies is progressively increasing. The most frequent drug-induced cutaneous manifestations are psoriasis-like, eczema-like, and lichenoid eruptions, as well as cutaneous lupus erythematosus for biologics, and nonmelanoma skin cancer, mainly basal cell and squamous cell carcinomas for thiopurines.
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D'Ugo S, Franceschilli L, Cadeddu F, Leccesi L, Blanco GDV, Calabrese E, Milito G, Di Lorenzo N, Gaspari AL, Sileri P. Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal. BMC Gastroenterol 2013; 13:47. [PMID: 23496835 PMCID: PMC3602071 DOI: 10.1186/1471-230x-13-47] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 02/28/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn's disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years. METHODS Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment. RESULTS Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications. CONCLUSIONS Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can't be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.
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Affiliation(s)
- Stefano D'Ugo
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Luana Franceschilli
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Federica Cadeddu
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Laura Leccesi
- Department of Internal Medicine, Catholic University, Rome, Italy
| | | | - Emma Calabrese
- Department of Gastroenterology, University Hospital Tor Vergata, Rome, Italy
| | - Giovanni Milito
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Nicola Di Lorenzo
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Achille L Gaspari
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Pierpaolo Sileri
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
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Clinical and genetic risk factors for perianal Crohn's disease in a population-based cohort. Am J Gastroenterol 2012; 107:589-96. [PMID: 22158027 DOI: 10.1038/ajg.2011.437] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Perianal Crohn's disease (CD) affects around one-quarter of CD patients and represents a distinct disease phenotype. The objective of this study was to investigate a large population-based cohort of inflammatory bowel disease (IBD) patients to identify clinical and genetic risk factors for perianal CD. METHODS Data were collected in the Canterbury IBD database, estimated to include 91% of all patients with IBD in Canterbury, New Zealand. Genotyping was performed for selected loci previously demonstrated to be associated with CD. Patients with perianal disease were then compared with both CD patients without perianal disease and healthy controls to assess the presence of potential phenotypic, environmental, and genetic risk factors. RESULTS Of the 715 CD patients in the database, 190 (26.5%) had perianal disease. In all, 507 patients with genotype data available were analyzed. Perianal disease was associated with younger age at diagnosis (P < 0.0001), complicated intestinal disease (P < 0.0001), and ileal disease location (P = 0.002). There was no association with gender, ethnicity, smoking, or breast feeding. Genotype analysis revealed an association with the neutrophil cytosolic factor 4 (NCF4) gene compared with both non-perianal CD patients (odds ratio (OR): 1.47; 95% confidence interval (CI): 1.08-1.99) and healthy controls (OR: 1.47; 95% CI: 1.10-1.95). There was no association identified with other genes, including IBD5 (OR: 0.91; 95% CI: 0.69-1.20), tumor necrosis factor α (OR: 1.04; 95% CI: 0.56-1.85), and IRGM (immunity-related guanosine triphosphatase protein type M) (OR: 1.21; 95% CI: 0.80-1.82). CONCLUSIONS This study suggests that younger age at diagnosis, complicated disease behavior, and ileal disease location are risk factors for perianal CD. In addition, this paper represents the first report of an association of the NCF4 gene with perianal disease.
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Abstract
Crohn's disease manifests with perianal or rectal symptoms in approximately one-third of patients, and is associated with a more aggressive natural history. Due to the chronic relapsing nature of the disease, surgery has been traditionally avoided. However, combined medical and surgical intervention when treating perianal fistulae has been shown to offer the best chance for success. Endoanal ultrasound examination or pelvic magnetic resonance imaging should be done in conjunction with an examination under anesthesia to characterize the disease. Any abscess should be drained and setons placed if there is active rectal inflammation or complex fistulae. Antibiotics and immunosuppressive therapy (especially with infliximab) should also be initiated. Simple fistulae can be treated surgically by fistulotomy or anal fistula plug. Complex fistulae can be closed with either an anal fistula plug or covered with flaps. Up to 20% of patients anorectal Crohn's disease require proctectomy for persistent and disabling disease.
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Affiliation(s)
- Robert T Lewis
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
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20
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Wijekoon NS, Samarasekera DN. The value of routine histopathological analysis in patients with fistula in-ano. Colorectal Dis 2010; 12:94-6. [PMID: 19175634 DOI: 10.1111/j.1463-1318.2008.01698.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the positive yield of routine histopathology in patients undergoing surgery for fistula in-ano. METHOD Histopathology reports of all the patients who underwent surgery for fistulae-in-ano over a period of 36 months were reviewed. RESULTS Analysis included 84 patients of which 73 (87%) were male subjects. The mean age was 39.4 years (range 11-68). Forty-one (49%) had recurrent fistulae. Granulomatous diseases such as Crohn's disease and tuberculosis (TB) were suspected in six patients. However, of the six patients, confirmation of the disease status was obtained only in three patients: stains for acid-fast bacilli confirmed TB in two (2.4%) patients and colonoscopy and biopsy confirmed Crohn's disease in one (1.2%) patient. All three patients had recurrent fistulae. CONCLUSION As the positive yield of routine histopathology is minimal, we do not recommend routine histopathology for fistula in-ano, except for those presenting with recurrent fistulae and those with clinical suspicion of an underlying disease such as TB, HIV or Crohn's disease.
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Affiliation(s)
- N S Wijekoon
- University Professorial Surgical Unit, The National Hospital of Sri Lanka, Colombo, Sri Lanka
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21
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Heo YJ, Park WK, Kim JC, Lee JK, Kim KY. Diagnosis and Treatment of Anorectal Lesions in Crohn's Disease. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2010. [DOI: 10.3393/jksc.2010.26.3.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | | | - Jae-Cheol Kim
- Department of Surgery, Hanam Song Do Colorectal Hospital, Hanam, Korea
| | - Jong-Kyun Lee
- Department of Surgery, Song Do Colorectal Hospital, Seoul, Korea
| | - Kwang-Yeon Kim
- Department of Surgery, Song Do Colorectal Hospital, Seoul, Korea
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Abstract
PURPOSE There is a subset of patients with perianal Crohn's disease whose course is unusually severe. The hypotheses of this study are that these patients often have direct perineal involvement with Crohn's disease and that this involvement can be recognized clinically. METHODS A prospective database with data from 1989 to 2005 was examined for patients with perianal Crohn's disease. Patients were divided into those with and those without perineal involvement, defined by the presence of at least one of the following findings: spontaneous perineal ulceration; nonhealing, painless fissures; or waxy perineal edema. Presentation, treatment, and outcome of the two groups were compared. RESULTS Seventy-two patients were identified, 19 with perineal involvement and 63 without. Perineal Crohn's disease was more often seen in women, presented at a younger age, and was associated with less small bowel and more colonic Crohn's. The chances of healing in patients with perineal Crohn's disease were lower (32 vs. 66 percent) and proctectomy was more likely (26 vs. 3.7 percent) than when the perineum was normal. CONCLUSION Perineal involvement with Crohn's disease can be diagnosed on physical examination and confirmed by the finding of granulomas. When perineal involvement is suspected, surgery should be avoided and consideration given to medical therapy.
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Bonheur JL, Braunstein J, Korelitz BI, Panagopoulos G. Anal skin tags in inflammatory bowel disease: new observations and a clinical review. Inflamm Bowel Dis 2008; 14:1236-9. [PMID: 18452201 DOI: 10.1002/ibd.20458] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The association between intestinal Crohn's disease (CD) and specific perianal abnormalities called anal skin tags (AST) has been recognized but not well defined. Skin tags have been classified into 2 types: 1) raised, broad, or narrow, single or multiple, soft or firm, and painless, often referred to as "elephant ears"; or 2) edematous, hard, often cyanotic, tender or not, and typically arising from a healed anal fissure, ulcer, or hemorrhoid. The aims of this study were to i) better characterize those skin tags identified by the term "elephant ears" and differentiate them from other types of AST; ii) compare their prevalence in patients with CD and ulcerative colitis (UC); iii) observe the relationship of the skin tags to the location of the primary bowel disease; and iv) to discuss the value of these typical AST in making an early diagnosis of CD. METHODS Photographs of all AST were taken when present at lower endoscopy in 170 consecutive patients with inflammatory bowel disease (IBD) seen in the private office of the senior investigator and Lenox Hill Hospital. Data was gathered with respect to major differences between the 2 types of AST. The location of the primary bowel disease for these patients was obtained from an extensive IBD computer database and review of details from charts. RESULTS Specific features of AST were described and served to favor type 1 versus type 2. AST were found more frequently in patients with CD (75.4%) as compared to patients with UC (24.6%), confirming previous observations that they are more diagnostic of CD (P = 0.005). Subset analysis revealed a trend with a greater incidence of AST in patients with colitis (46.9%) as compared to patients with ileitis (36.7%) and ileocolitis (16.3%) (P = 0.067). CONCLUSIONS We provide photographs with the most characteristic features of AST and attempt to separate elephant ears (type 1) from less typical AST (type 2) in CD. Our study confirms previous reports that AST are more commonly found in association with CD as compared with UC and more so in the presence of disease limited to the colon as compared to disease elsewhere in the bowel. Our observations support the diagnostic significance of AST heralding the diagnosis of CD when they are discovered on physical exam, especially in young people with diarrhea, abdominal pain, and/or growth retardation.
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Affiliation(s)
- Jennifer L Bonheur
- Department of Gastroenterology, Lenox Hill Hospital, and New York University School of Medicine, New York, New York 10021, USA.
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Palamaras I, El-Jabbour J, Pietropaolo N, Thomson P, Mann S, Robles W, Stevens HP. Metastatic Crohn's disease: a review. J Eur Acad Dermatol Venereol 2008; 22:1033-43. [DOI: 10.1111/j.1468-3083.2008.02741.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Angelberger S, Reinisch W, Dejaco C, Miehsler W, Waldhoer T, Wehkamp J, Lichtenberger C, Schaeffeler E, Vogelsang H, Schwab M, Teml A. NOD2/CARD15 gene variants are linked to failure of antibiotic treatment in perianal fistulating Crohn's disease. Am J Gastroenterol 2008; 103:1197-202. [PMID: 18371140 DOI: 10.1111/j.1572-0241.2007.01741.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The Crohn's disease (CD) susceptibility gene, nucleotide-binding oligomerizetion domain 2 (NOD2)/caspase recruitment domain 15 (CARD15), is linked to the innate immune response associated with altered epithelial bacterial defense. Its relevance in antibiotic therapy of perianal fistulating CD remains elusive. The aim of the study was to explore systematically the association between NOD2/CARD15 variants and clinical response of perianal fistulas in patients using antibiotic therapy. METHODS Fifty-two patients (median age 36 yr) with draining perianal fistulas were treated with ciprofloxacin (N = 49) or metronidazole (N = 3) for a median duration of 7 wk. Complete response was defined as the absence of any draining fistula despite gentle finger compression. Genotyping for NOD2/CARD15 variants and human beta (beta)-defensin 2 (HBD-2) copies was performed by 5' nuclease assays (Applied Biosystems, Foster City, CA). The examiners and laboratory investigators were blinded. The Fisher exact test and Wilcoxon signed rank test were used for statistical analysis. RESULTS Ciprofloxacin was discontinued in one patient due to diarrhea after 2 wk. Complete fistula response was observed in 13 of 39 patients with NOD2/CARD15 wild-type (33.3%) compared with none in patients carrying NOD2/CARD15 variants (0%, P= 0.02). The median number of HBD-2 gene copies between responders and partial/nonresponders was similar. CONCLUSIONS The study result suggests a substantial contribution of NOD2/CARD15 to the antibiotic treatment outcome of perianal fistulating CD. NOD2/CARD15 variants may predispose to an altered intestinal microflora in perianal fistulas that is less responsive to antibiotic treatment.
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Affiliation(s)
- Sieglinde Angelberger
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University Vienna, Vienna, Austria
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Colon, Rectum, and Anus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Crohn's disease is commonly complicated by perianal manifestations. The surgeon plays a pivotal role in caring for these patients; a detailed history along with a thorough clinical exam provides the treating physician with invaluable information upon which to base further investigations and management decisions. Other than abscess drainage, medical management to control proximal disease often precedes any surgical attempt to cure the disease. Surgical interventions are indicated in selective patients, but are often complicated by poor wound healing and recurrences. A sizable percentage of these patients may need a proctectomy.
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Affiliation(s)
- Bashar Safar
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Dana Sands
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
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Ingle SB, Loftus EV. The natural history of perianal Crohn's disease. Dig Liver Dis 2007; 39:963-9. [PMID: 17720635 DOI: 10.1016/j.dld.2007.07.154] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 12/11/2022]
Abstract
Perianal lesions are exceedingly common in Crohn's disease and many patients have more than one type of lesion. Skin tags, fissures and haemorrhoids may persist over time and are usually managed expectantly or with topical therapy. Perianal and rectovaginal fistulas and associated abscesses often require both local and systemic therapy, and recurrence is common. In general, the clinical course of Crohn's disease is more aggressive in patients with perianal involvement. Established risk factors for perianal disease include colonic disease and young age at disease onset. Classification schema now recognize perianal fistulas as distinct from other forms of penetrating Crohn's disease. Genetic susceptibility factors for perianal disease may exist, but they remain incompletely delineated at present. There is hope that immunosuppressive and biotechnology medications will influence the natural history of perianal disease by preventing invasive surgeries, disease complications and recurrence, but this needs to be confirmed. Cancer, a rare complication of perianal disease, must be suspected when lesions persist despite therapy.
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Affiliation(s)
- S B Ingle
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Affiliation(s)
- S Ardizzone
- Department of Clinical Science, L. Sacco University Hospital, Milan, Italy
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30
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Lee IS, Choe EK, Park SC, Park KJ. Crohn's Anal Fistula and Perianal Abscess: Results of Surgical Treatment. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2007. [DOI: 10.3393/jksc.2007.23.6.424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- In Seob Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Kyung Choe
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Chan Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Keese M, Back W, Dinter D, Gladisch R, Joos A, Palma P. Case report: late perianal mucinous adenocarcinoma after Crohn's disease proctectomy: an oncological rarity. World J Surg Oncol 2005; 3:42. [PMID: 15987512 PMCID: PMC1190221 DOI: 10.1186/1477-7819-3-42] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2005] [Accepted: 06/29/2005] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND As in ulcerative colitis, there is an increased incidence of colorectal carcinoma in Crohn's disease. While carcinoma formation originating from ano-rectal fistulas is generally considered as a rare event there are different publications reporting on mucinous adenocarcinoma formation in association with a neovagina and rectovaginal fistulas. To the best of our knowledge this is the first description of a perianal mucinous adenocarcinoma arising in a patient after Crohn's disease proctocolectomy. CASE PRESENTATION We report the case of a 50-year old female with a mucinous adenocarcinoma forming in the perineum eleven years after proctocolectomy for Crohn's disease. The patient was readmitted with perineal pain, leucocytosis and a perineal mass highly suspicious of abscess formation in the MRI-Scan. Histological examination revealed a mucinous adenocarcinoma. Exenteration including vagina, uterus and ovaries together with the coccygeal-bone was performed. CONCLUSION Mucinous adenocarcinoma formation is a rare complication of Crohn's disease and so far unreported after proctocolectomy.
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Affiliation(s)
- Michael Keese
- Department of Surgery, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Walter Back
- Department of Pathology, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Dietmar Dinter
- Department of Radiology, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Rainer Gladisch
- Department of Medicine, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Andreas Joos
- Department of Surgery, University Hospital of Mannheim, 68135 Mannheim, Germany
| | - Pablo Palma
- Department of Surgery, University Hospital of Mannheim, 68135 Mannheim, Germany
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Abstract
Perianal manifestations of Crohn's disease usually coexist with active inflammation of other primary sites of the disease. Although treatment of active proximal disease may sometimes alleviate perianal symptoms, it is reasonable to separately treat symptomatic perianal disease. The diversity of perianal manifestations in Crohn's disease mandates a tailored, individualized approach in every case. Medical therapy is the best treatment option for hemorrhoids and anal fissures. The medical management of patients with perianal Crohn's disease includes the use of systemic antibiotics, immunosuppressive agents, and infliximab. Infliximab is now recognized as a very efficacious agent for treating fistulizing Crohn's disease, including perianal fistulae. It may also reduce the need for surgical intervention in specific cases. Abscesses and fistulae are treated by control of sepsis, resolution of inflammation and optimal preservation of continence, and quality of life. Abscesses require surgical drainage that may need to be prolonged to achieve complete healing. Fistulae may be treated medically, especially in cases of concurrent proctitis. Refractory fistulae may require surgical treatment including an occasional need for fecal diversion or proctectomy. The role of new treatment options such as natalizumab and CDP571 is evolving and requires further investigation.
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Affiliation(s)
- Benjamin Person
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
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Baccouche D, Sriha B, Denguezli M, Belajouza C, Nouira R, Korbi S. [Peri anal tumor]. Ann Dermatol Venereol 2005; 132:375-7. [PMID: 15886570 DOI: 10.1016/s0151-9638(05)79288-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- D Baccouche
- Service de Dermatologie, CHU Farhat Hached, 4002 Sousse, Tunisie
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Abstract
BACKGROUND The management of perianal Crohn's disease is difficult. A wide variety of treatment options exist although few are evidence based. METHODS A search was conducted using the National Library of Medicine for articles on perianal Crohn's disease and its incidence, classification, assessment and management. RESULTS AND CONCLUSION Perianal Crohn's disease can manifest as skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Improved radiological imaging with endoanal anal ultrasonography and magnetic resonance imaging has improved its assessment and may be used to predict outcome after surgery. Many treatment options exist. During acute complications they are generally aimed at resolving the immediate problem and limiting damage to anal and perianal tissues; this may be a 'bridge' to definitive treatment. The likelihood of success of definitive treatment must be weighed against the risk of complications, especially faecal incontinence.
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Affiliation(s)
- B Singh
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
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Affiliation(s)
- William J Sandborn
- Clinical Practice Committee, AGA National Office, c/o Membership Department, 4930 Del Ray Avenue, Bethesda, MD 20814, USA
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Goyal A, Nadler EP, Ford HR, Keljo DJ. Treatment of Fistulizing Crohn's Disease in Children. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2003; 6:391-402. [PMID: 12954146 DOI: 10.1007/s11938-003-0042-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Patients with Crohn's disease are at risk for developing both internal and external fistulae. These can be asymptomatic incidental radiologic findings or causes of incontinence, chronic pain, abscesses, and sepsis. They can have a devastating impact on quality of life. Careful prospective studies of therapy are few in adult medicine and entirely lacking in the pediatric age group. Assessment and management require a coordinated effort between gastroenterologist, radiologist, and surgeon. Principles of management include surgical drainage of infection combined with medical therapy. Only infliximab has been studied in prospective, double-blinded fashion and clearly shown to be of use in the short term. There is good evidence that metronidazole may be useful acutely and that 6-mercaptopurine azathioprine may help to maintain closure. Diverting ostomies are of very limited value and corticosteroids seem to make matters worse. There are many other therapies that have been reported to be helpful in small, uncontrolled studies.
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Affiliation(s)
- Alka Goyal
- Departments of Gastroenterology and Surgery, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213-2583, USA.
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Basu A, Wexner SD. Perianal Crohn's Disease. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2002; 5:197-206. [PMID: 12003714 DOI: 10.1007/s11938-002-0041-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Perianal Crohn's disease usually is associated with involvement of another primary site of Crohn's disease. However, there is conflicting evidence on the relationship between proximal disease activity and perianal symptoms. Therefore, although it is reasonable to treat active proximal disease, symptomatic perianal disease may have to be treated on its own right. Hemorrhoids and anal fissures are best treated medically. Fistulae and abscesses are treated with control of sepsis and resolution of inflammation while preserving continence and quality of life. Abscesses require surgical drainage, which needs to be prolonged for healing to be complete. Fistulae may be treated with medications first, especially if the rectum is diseased. Refractory fistulae respond better to surgical treatment and sometimes require fecal diversion. The medical management of patients with perianal Crohn's disease consists of rectal mesalamine, systemic antibi-otics, immunosuppressive agents, and infliximab. The role of infliximab is evolving and it may reduce the need for surgical intervention in some cases. Perianal hygiene and skin protection help to reduce local discomfort.
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Affiliation(s)
- Abhijit Basu
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Boulevard, Weston, FL 33331, USA.
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Schwartz DA, Loftus EV, Tremaine WJ, Panaccione R, Harmsen WS, Zinsmeister AR, Sandborn WJ. The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota. Gastroenterology 2002; 122:875-80. [PMID: 11910338 DOI: 10.1053/gast.2002.32362] [Citation(s) in RCA: 704] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Little is known about the cumulative incidence and natural history of fistulas in Crohn's disease in the community. METHODS The medical records of all Olmsted County, Minnesota residents who were diagnosed with Crohn's disease from 1970 to 1993 and who developed a fistula were abstracted for clinical features and outcomes. Six patients denied research authorization. The cumulative incidence of fistula from time of diagnosis was estimated by using the Kaplan-Meier product-limit method. RESULTS At least 1 fistula occurred in 59 patients (35%), including 33 patients (20%) who developed perianal fistulas. Twenty-six (46%) developed a fistula before or at the time of formal diagnosis. Assuming that the 9 patients with fistula before Crohn's disease diagnosis were instead simultaneous diagnoses, the cumulative risk of any fistula was 33% after 10 years and was 50% after 20 years (perianal, 21% after 10 years and 26% after 20 years). At least 1 recurrent fistula occurred in 20 patients (34%). Most fistulizing episodes (83%) required operations, most of which were minor. However, 11 perianal fistulizing episodes (23%) resulted in bowel resection. CONCLUSIONS Fistulas in Crohn's disease were common in the community. In contrast to referral-based studies, only 34% of patients developed recurrent fistulas. Surgical treatment was frequently required.
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Affiliation(s)
- David A Schwartz
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
Anorectal disease affects many patients with Crohn's disease. Clinical manifestations vary from asymptomatic skin tags to severe, debilitating perineal destruction and sepsis. Surgical management needs to be conservative and must focus on draining septic sites, preserving sphincter function, and palliating symptoms. Medical management has had some success in improving symptoms, but as yet, it has not been able to ameliorate most perianal complaints quickly and enduringly. Many new and exciting treatment modalities are being investigated with the hope that more effective approaches to these complex and difficult problems can be realized.
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Affiliation(s)
- S J McClane
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio, USA
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40
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41
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Abstract
Tube loop seton drainage treatment of multiply recurring high-spreading extrasphincteric perianal fistulae in 19 patients is reported in this study. The drainage loop setons make possible the rinsing of the wound following fistulectomy and also the bidirectional drainage of the wound discharge. Strangulation of the wound and an early closure of the fistula and hence the development of recurrence is prevented by means of controlled formation of scarred tissue. The sphincteral musculature of the anus is also protected from damage. Thirty-five recurring fistulae of 19 patients included in the present study were treated successfully by this method. Two fistula recurred. None of these patients developed incontinence. The use of tube loop setons was found to have advantages over the pull-out method in cases of high-spreading multiply recurring extrasphincteric or suprasphincteric perianal fistulae.
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Affiliation(s)
- G Balogh
- Second Department of Surgery and Thoracic Surgery, Kaposi Mor County Hospital, Kaposvar, Hungary
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43
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Abstract
These complex anorectal conditions are difficult to diagnose because clinical features overlap. In general, an aggressive approach is reserved for hidradenitis suppurativa and necrotizing infections. Patients with Crohn's disease, hematologic disorders, or AIDS are often treated more conservatively, but the correct timing and degree of aggressiveness of surgical intervention may considerably improve the overall outcome. The increasing incidence of AIDS and the frequency with which infected patients present to surgical clinics make it imperative that all surgeons have a working knowledge of the conditions associated with this syndrome. Expertise is required not only to diagnose and treat these conditions but also to protect oneself and others from being inadvertently infected with the HIV. A high index of suspicion and constant vigilance permit the successful resolution of many of these challenging problems.
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Affiliation(s)
- R Gilliland
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, USA
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Sangwan YP, Schoetz DJ, Murray JJ, Roberts PL, Coller JA. Perianal Crohn's disease. Results of local surgical treatment. Dis Colon Rectum 1996; 39:529-35. [PMID: 8620803 DOI: 10.1007/bf02058706] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE This study relates our experience with local surgical management of perianal Crohn's disease. METHOD Of 1,735 patients with Crohn's disease seen between 1980 and 1990, records of 66 patients (3.8 percent) with symptomatic perianal Crohn's disease treated by local operations were retrospectively reviewed to study outcome of local surgical intervention. RESULTS All patients had intestinal disease that was limited to the colon in 32 patients (48 percent), ileocolonic region in 22 patients (33 percent), and ileum in 12 patients (18 percent). Types of perianal disease encountered included perianal suppuration (57), anal fistula (47), anal fissure (21), anal stenosis (5), gluteal abscess (3), scrotal abscess (2), and anovaginal fistula (2). A total of 321 episodes of anal complications necessitated 256 local surgical interventions. Local anorectal operations performed included simple incision and drainage of abscess (57), fistulotomy (35), incision and drainage of complex anorectal abscesses and fistulas and insertion of seton (24), internal sphincterotomy (6), fissurectomy (1), and anal dilation (3). Of 24 patients with horseshoe abscesses and fistulas managed with insertion of a seton and 35 patients who underwent fistulotomy as a primary procedure or in conjunction with drainage of an abscess, none experienced fecal incontinence as a direct result of the operation. Thirteen patients required proctectomy to control perianal disease, and a similar number underwent total proctocolectomy for extensive intestinal disease. Forty patients (61 percent) continue to retain a functional anus. CONCLUSION Patients with symptomatic low anal fistula involving minimum sphincter musculature can be treated safely with fistulotomy. In treatment of patients with horseshoe abscesses and high fistulas, aggressive local surgical intervention using a seton permits preservation of the sphincter and good postoperative function.
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Affiliation(s)
- Y P Sangwan
- Department of Colon and Rectal Surgery, Lahey Hitchcock Medical Center, Burlington, Massachusetts, USA
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45
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Fleshner PR, Schoetz DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC. Anal fissure in Crohn's disease: a plea for aggressive management. Dis Colon Rectum 1995; 38:1137-43. [PMID: 7587755 DOI: 10.1007/bf02048328] [Citation(s) in RCA: 86] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was undertaken to identify clinical characteristics, natural history, and results of medical and surgical treatment of anal fissures in Crohn's disease. METHODS This is a retrospective review of patients with Crohn's disease and anal fissure. RESULTS Of the 56 study patients, 49 (84 percent) had symptomatic fissures. Fissures were most commonly (66 percent) located in the posterior midline, and 18 patients (32 percent) had multiple fissures. Fissures healed in one-half of patients treated medically. Factors predictive of successful medical treatment included male gender, painless fissure, and acute fissure. Of 15 patients, 10 (67 percent) treated surgically healed. Fissures in seven of eight patients (88 percent) who underwent anorectal procedures healed compared with fissures in only three of seven patients (43 percent) who underwent proximal intestinal resection. In the group of 50 patients with complete follow-up studies, an anal abscess or fistula from the base of an unhealed fissure developed in 13 patients (26 percent). More fissures healed after anorectal surgery (88 percent) than after medical treatment alone (49 percent; P = 0.05) or after abnormal surgery (29 percent; P = 0.03). CONCLUSION This series documents that unhealed fissures frequently progress to more ominous anal pathologic disease. Judicious use of internal sphincterotomy appears to be safe for fissures unresponsive to medical treatment.
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Affiliation(s)
- P R Fleshner
- Department of Colon and Rectal Surgery, Lahey Hitchcock Clinic, Burlington, Massachusetts 01805, USA
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Pescatori M, Interisano A, Basso L, Arcanà F, Buffatti P, Di Bella F, Doldi A, Forcheri V, Gaetini R, Pera A. Management of perianal Crohn's disease. Results of a multicenter study in Italy. Dis Colon Rectum 1995; 38:121-4. [PMID: 7851164 DOI: 10.1007/bf02052437] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Management of perianal Crohn's disease is still controversial, and reports on large series are very few in the literature. The aim of this multicenter study was to investigate the outcome of both medical and surgical treatment in 225 patients. METHODS Patients cared for at different institutions were followed up for a median of six years. Most of them had either anal fistula or an abscess (86 percent and 43 percent, respectively), but fissures were also present in 26 percent of the cases. Diarrhea and anal pain were the most common symptoms. Anal lesions preceded the onset of intestinal symptoms in 19 percent of cases. RESULTS Medical treatment was curative only in 21 of 123 patients. Overall, medical and surgical treatment either cured or improved 62 percent of the cases. Fifty percent had an intestinal resection. Abscess drainage and fistulotomy were the most common anal surgeries. Rectovaginal fistulas (n = 30) required intestinal surgery in 36 percent and anal surgery in 20 percent of the cases, 50 percent with good results. Of 166 patients who had anal surgery, 97 (58 percent) had a positive outcome. Recurrence of anal disease requiring further surgery occurred in 24.5 percent of the cases. CONCLUSIONS Limited surgeries seem to achieve satisfactory results in more than one-half of the patients affected by perianal Crohn's lesions, whereas medical treatment alone is curative in a small portion of them.
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Domizio P. Pathology of chronic inflammatory bowel disease in children. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1994; 8:35-63. [PMID: 8003743 DOI: 10.1016/s0950-3528(06)80018-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The term chronic inflammatory bowel disease is usually applied to the idiopathic varieties ulcerative colitis and Crohn's disease but actually encompasses a wide range of colonic inflammatory conditions, which in children includes indeterminate colitis, microscopic colitis, allergic colitis and Behçet's enterocolitis. The pathologist's opinion is considered the final arbiter in the diagnosis of inflammatory bowel disease but classification may be hampered by the considerable histological overlap between the various types of colitis. Accurate diagnosis, particularly in biopsy specimens, thus depends on clinical and radiological input as well as on appropriately selected and adequately prepared material. This chapter discusses in detail the morphological appearances of ulcerative colitis and Crohn's disease with particular emphasis on diagnosis by mucosal biopsy and differential diagnosis in the paediatric age group. The recent demonstration of ulceration-associated cell lineage and trefoil peptide expression in inflammatory bowel disease is also discussed.
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Affiliation(s)
- P Domizio
- Department of Histopathology, Medical College of St Bartholomew's Hospital, West Smithfield, London, UK
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Allan A, Linares L, Spooner HA, Alexander-Williams J. Clinical index to quantitate symptoms of perianal Crohn's disease. Dis Colon Rectum 1992; 35:656-61. [PMID: 1611953 DOI: 10.1007/bf02053756] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We describe an anal disease activity index suitable for use in prospective studies of treatment and recording the natural history of anal disease. We studied 40 patients with perianal Crohn's disease (PACD), 14 patients with anal disease not related to Crohn's disease, and 10 normal individuals. Seven symptoms related to anal disease were measured using a linear analog scoring system, which proved easy for the patients to complete. Only three of the seven clinical parameters studied before and after treatment had a high discriminant value. On the basis of these findings, we conclude that a good index of response to therapy in patients with anal disease can be obtained from a linear analog scoring of three symptoms: spontaneous anal pain, pain following defecation, and inhibition of locomotion by pain. The index should be of value in comparing management options in PACD.
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Affiliation(s)
- A Allan
- Department of Surgery, General Hospital, Brimingham, United Kingdom
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Cohen JL, Stricker JW, Schoetz DJ, Coller JA, Veidenheimer MC. Rectovaginal fistula in Crohn's disease. Dis Colon Rectum 1989; 32:825-8. [PMID: 2791765 DOI: 10.1007/bf02554548] [Citation(s) in RCA: 34] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Rectovaginal fistulas in the setting of Crohn's disease present a difficult management dilemma. Some patients with this problem require proctocolectomy, yet other patients with minimal symptoms never require an operation for treatment of the rectovaginal fistula. For a small percentage of patients, local surgical repair of the fistula may be warranted. Since 1980, this study has attempted local repair in seven patients with symptomatic rectovaginal fistulas from Crohn's disease. Five patients underwent staged repair of the fistula. Closure of the colostomy was eventually possible in three of these patients. Two of the three patients have had no evidence of recurrence at followup in excess of two years. The third patient required an ileostomy for intestinal disease and had no recurrence of the fistula. Two patients underwent primary repair of the rectovaginal fistula without fecal diversion; in one of these patients, the fistula recurred ten days after operation, necessitating a diverting ileostomy. The other patient remains cured 26 months after repair. The results of this review indicate that in the setting of quiescent rectal disease, an attempt to repair the fistula can be expected to have a reasonable chance of success. The presence of a rectovaginal fistula in a patient with Crohn's disease does not mandate removal of the rectum.
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Affiliation(s)
- J L Cohen
- Department of Colon and Rectal Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts
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50
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Morrison JG, Gathright JB, Ray JE, Ferrari BT, Hicks TC, Timmcke AE. Surgical management of anorectal fistulas in Crohn's disease. Dis Colon Rectum 1989; 32:492-6. [PMID: 2791786 DOI: 10.1007/bf02554504] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A retrospective review of patients with Crohn's disease treated at our institution from 1973 to 1986 revealed 35 patients operated upon for anorectal fistulas. Twenty-nine had low intermuscular fistulas (multiple in seven), and six had high intermuscular (supralevator) fistulas. Fistulotomy alone was performed in 19 patients, and eight underwent partial fistulotomy and seton insertion. Five additional patients had proximal fecal diversion before fistulotomy. Three patients with severe colonic and anorectal disease underwent proctocolectomy as the initial procedure. Of the 32 patients who had fistulotomy performed, complete healing occurred in 30. Seven patients who healed required more than one operation for fistula. One patient was left with an asymptomatic fistula, and one required proctectomy for persistent symptomatic fistula and proctitis. Success of operation correlated with absence of rectal disease and quiescent disease elsewhere in the gastrointestinal tract. Aggressive medical treatment is required to control bowel disease preoperatively. In the majority of patients, subsequent surgery is justified and healing can be anticipated.
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Affiliation(s)
- J G Morrison
- Department of Colon and Rectal Surgery, Ochsner Clinic, New Orleans, Louisiana 70121
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