Treatment of Perianal Crohn's Disease: State of the Art

Aaron Brzezinski, MD,andBret A. Lashner, MD

Disclosures

Introduction

Anal involvement can be the initial presentation in up to 5% of patients with Crohn's disease, and over a lifetime as many as one third of patients will have symptoms or complications from involvement of the anoperineal region. From a purist's viewpoint, anal involvement is different from rectal disease. However, for practical purposes, rectal involvement is frequently considered part of anoperineal disease. Traditionally, the treatment of patients with Crohn's disease has focused on decreasing symptoms, improving quality of life, and decreasing complications related to either the disease process or its therapy. Anal and perianal complications of Crohn's disease represent a major challenge for both the gastroenterologist and colorectal surgeon.

Anoperineal disease is one manifestation of Crohn's disease that significantly adversely affects patient quality of life. The spectrum of involvement includes prominent perianal skin tags, fissures, ulcers, abscesses, fistulas, and stricture -- at times, disease can be so extensive that it leads to destructive lesions of the anoperineum. Fistulas can be internal, external, or mixed; single or multiple; or simple or complicated. Anoperineal involvement can lead to social isolation because patients have urgency, frequency, and stool incontinence that can be related to either the disease itself or the iatrogenic complications. Other symptoms include pain, soiling, sleep disruption, sexual dysfunction, and sepsis. The treatment of patients with anoperineal disease frequently entails stool diversion by the creation of a stoma to improve symptoms and manage infectious complications, or placement of noncutting seton sutures that allow for continued open drainage of purulence.

It is important to use a multidisciplinary approach to optimally evaluate and treat these patients. The gastroenterologist and the colorectal surgeon must work together, given that adequate examination under anesthesia and surgical treatment of septic complications are often both needed in addition to long-term medical therapy. Prior to initiating therapy, the type of fistulous disease must be classified. This usually involves a colorectal surgery examination under anesthesia (EUA) and an endoscopic ultrasound of the anoperineum to determine the extent of fistulous disease and the degree of involvement of the anal sphincters. Once the type and extent of involvement has been determined, a rational approach to management can be devised that should include: (1) medical treatment for simple or complex fistulas with active mucosal inflammation or (2) surgical-medical treatment for fistulous disease and sinuses, disease complicated by abscess, disease with a minimal inflammatory component, and disease in which an internal os cannot be visualized.

Whether this strategy will lead to a better outcome than medical or surgical treatment alone has not been determined. To design and perform a trial to evaluate the efficacy of this approach would be very difficult, given the large number of patients and long follow-up that would be required. However, with the information currently available, we propose the following algorithm as a means of approaching the treatment of patients with Crohn's disease involving the anoperineal region:

The review titled "Treatment of Perianal Crohn's Disease: State of the Art," by Dr. Schwartz and Dr. Sandborn in this issue of Medscape Gastroenterology carefully presents the existing information on the medical therapy of perianal Crohn's disease. Such therapy will only be effective if all of the septic material is drained during EUA and if surgical therapies, such as advancement flap surgery or mushroom catheter placement, are deemed inappropriate. When surgical therapy is appropriate, however, recent series have reported a 70% long-term success rate, without the need for potent and potentially toxic immunosuppressive agents.

Treatment of perianal Crohn's disease remains a great challenge for clinicians and offers an excellent opportunity for gastroenterologists and colorectal surgeons to cooperate for the delivery of optimal patient care.

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