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

Disclosures

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

In This Article

Abstract and Introduction

Abstract

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.

Introduction

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.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....