Long-term Outcome of Non-fistulizing (Ulcers, Stricture) Perianal Crohn's Disease in Patients Treated with Infliximab

G. Bouguen; I. Trouilloud; L. Siproudhis; A. Oussalah; M.-A. Bigard; J.-F. Bretagne; L. Peyrin-Biroulet


Aliment Pharmacol Ther. 2009;30(7):749-756. 

In This Article

Abstract and Introduction


Background: In Crohn's disease, anal ulcers and stricture can be disabling.
Aim: To evaluate long-term outcome of non-fistulizing perianal Crohn's disease under infliximab.
Methods: The medical records of 99 patients with non-fistulizing perianal Crohn's disease at first infliximab infusion were reviewed. Complete responses (ulcer healing or stricture regression) after induction infliximab therapy and at the maximal follow-up were assessed.
Results: Ninety-four patients (94.9%) had ulcers, 22 (22.2%) had stricture and 31 (31.3%) had draining perianal fistulas at first infliximab infusion. After infliximab induction therapy, 40/94 (42.5%) patients with ulcers, 4/22 (18.2%) with stricture and 10/31 (32.2%) with fistulas had a complete response. Eight patients were lost to follow-up. After a median follow-up of 175 weeks (range, 13–459), complete response rates for ulcers, stricture and fistulas were 72.3% (68/94), 54.5% (12/22) and 54.8% (20/31) respectively. Long-term response for cavitating ulcer was positively associated with concomitant immunosuppressant use (P = 0.017) and older age (P = 0.049). Among the 12 patients with complete regression of stricture, 6 patients also had anal dilatation. Complete response was associated with perianal pain relief and disappearance of soiling. Three patients with ulcers developed an anal abscess.
Conclusions: Infliximab therapy may be effective in inducing and maintaining response for ulcers.


Perianal Crohn's disease (PCD) encompasses non-fistulizing (fissures, ulcers and strictures) and fistulizing lesions (fistulas, abscesses and rectovaginal fistulas).[1]

Superficial fissures constitute 21–35% of perianal lesions,[2,3] cavitating ulcers occur in the anus and rectum with an incidence of 5–10%[4–6] and anorectal strictures were noted in 9–22% of patients.[3,4] For cavitating ulcer, pain is often severe and is unremitting in up to 56% of cases.[5] While Crohn's disease anal fissures are classically described as painless, anal discomfort with symptoms including pain, discharge, pruritus and bleeding has been reported in 44–70% in referral centre-based series.[7,8] Although anorectal strictures and stenosis are often asymptomatic, proctocolectomy may be required in up to 43% of patients.[9]

The treatment of non-fistulizing PCD remains a challenge in clinical practice. In a retrospective study,[7] medical treatment including steroids, antibiotics or amino-salycilate healed fissures in 46% of 52 patients after a median follow-up of 92 months. In two patients with perianal ulcers treated with thalidomide, one achieved clinical response and the other one showed initial improvement with reduction in ulcer size and drainage at 1 year,[10] Ciclosporin treatment healed 70% of perianal ulcers in 20 patients after a median follow-up of 7 months.[11] Regarding topical treatment, 10% metronidazole decreased the Perianal Crohn's Disease Activity Index and anorectal pain in 14 patients at 4 weeks,[12] whereas tacrolimus did not heal ulcers, but led to rapid improvement in terms of depth, surface area and pain in 4 patients after 3 months,[13,14] Local depot methylprednisolone injection also showed some efficacy in treating painful anal Crohn's disease in 5 patients with a follow-up of 12 months.[15] Two reports suggested a beneficial effect of hyperbaric oxygen in 8 patients.[16,17] Anal surgery may be considered for fissures unresponsive to medical treatment.[2,7,18] Overall, these results remain difficult to interpret because of small sample sizes and the lack of a control arm.

Over the last decade, tumour necrosis factor (TNF) antagonists including infliximab (Remicade; Centocor, Malvern, PA, USA) have changed the way of treating both luminal and fistulizing Crohn's disease refractory to standard medications.[19] Only one study evaluated its potential for treating non-fistulizing perianal ulcers. At 24 weeks, 8 out of 16 patients had healed perianal ulcers.[20] As that series was small (n = 30), the follow-up was short (6 months) and only infliximab induction therapy was administered, no definitive conclusions could be drawn from that study.[20]

The aim of the present study was to evaluate the long-term outcome of non-fistulizing PCD, e.g. ulcers (superficial fissure, cavitating ulcer) and stricture in a large cohort of patients treated with infliximab.


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