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Clin Colon Rectal Surg 2022; 35(01): 051-057
DOI: 10.1055/s-0041-1740038
Review Article

A Multi-Disciplinary Approach to Perianal Fistulizing Crohn's Disease

Jacob Wiseman   *
1   Division of Gastroenterology, Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
,
Tanya Chawla   *
2   Mount Sinai Hospital, Department of Medical Imaging, Toronto, Ontario, Canada
,
Frederic Morin
3   Department of Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada
,
Anthony de Buck van Overstraeten
3   Department of Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada
,
Adam V. Weizman
1   Division of Gastroenterology, Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Abstract

Perianal fistulizing Crohn's disease represents a severe phenotype associated with significant morbidity. Patients with perianal fistulizing disease are more likely to have a severe disease course and have significant reductions in quality of life. Moreover, these patients are at risk for the development of distal rectal and anal cancers. Given the complexity and severity of this patient group, the management of perianal Crohn's disease must be undertaken by a multidisciplinary team. The gastroenterologist and colorectal surgeon play a critical role in the diagnosis and management of perianal fistulizing disease. An examination under anesthesia provides critical information and is an essential part of the work-up of complex perianal fistulas. The radiologist also plays a central role in characterizing anatomy and assessing response to treatment. Several imaging modalities are available for these patients with magnetic resonance imaging as the imaging modality of choice. Perianal disease developing after ileal pouch-anal anastomosis represents a particularly challenging form of fistulizing disease and requires a multidisciplinary clinical and radiologic approach to differentiate surgical complications from recurrent Crohn's disease.

Keywords

Crohn's disease - examination under anesthesia - inflammatory bowel disease - magnetic resonance imaging - perianal fistula

* Co-principal author.




Publication History

Article published online:
17 January 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Benchimol EI, Bernstein CN, Bitton A. et al. The impact of inflammatory bowel disease in Canada 2018: a scientific report from the Canadian Gastro-Intestinal Epidemiology Consortium to Crohn's and Colitis Canada. J Can Assoc Gastroenterol 2019; 2 (Suppl. 01) S1-S5
    PubMedGoogle Scholar
  • 2 Beaugerie L, Seksik P, Nion-Larmurier I, Gendre JP, Cosnes J. Predictors of Crohn's disease. Gastroenterology 2006; 130 (03) 650-656
    CrossrefPubMedGoogle Scholar
  • 3 Wewer MD, Zhao M, Nordholm-Carstensen A. et al. The incidence and disease course of perianal Crohn's disease: a Danish Nationwide Cohort Study, 1997–2015. J Crohns Colitis 2020; 15 (01) 5-13
    CrossrefPubMedGoogle Scholar
  • 4 Panés J, Rimola J. Perianal fistulizing Crohn's disease: pathogenesis, diagnosis and therapy. Nat Rev Gastroenterol Hepatol 2017; 14 (11) 652-664
    CrossrefPubMedGoogle Scholar
  • 5 Wright EK, Kamm MA. Impact of drug therapy and surgery on quality of life in Crohn's disease: a systematic review. Inflamm Bowel Dis 2015; 21 (05) 1187-1194
    CrossrefPubMedGoogle Scholar
  • 6 Lightner AL, Faubion WA, Fletcher JG. Interdisciplinary management of perianal Crohn's disease. Gastroenterol Clin North Am 2017; 46 (03) 547-562
    CrossrefPubMedGoogle Scholar
  • 7 Schwartz DA, Ghazi LJ, Regueiro M. et al; Crohn's & Colitis Foundation of America, Inc. Guidelines for the multidisciplinary management of Crohn's perianal fistulas: summary statement. Inflamm Bowel Dis 2015; 21 (04) 723-730
    CrossrefPubMedGoogle Scholar
  • 8 Park SH, Aniwan S, Harmsen WC. et al. Update on the natural course of fistulizing perianal Crohn's disease in a population-based cohort. Inflamm Bowel Dis 2019; 25 (06) 1054-1060
    CrossrefPubMedGoogle Scholar
  • 9 Göttgens KWA, Jeuring SFG, Sturkenboom R. et al. Time trends in the epidemiology and outcome of perianal fistulizing Crohn's disease in a population-based cohort. Eur J Gastroenterol Hepatol 2017; 29 (05) 595-601
    CrossrefPubMedGoogle Scholar
  • 10 Eglinton TW, Barclay ML, Gearry RB, Frizelle FA. The spectrum of perianal Crohn's disease in a population-based cohort. Dis Colon Rectum 2012; 55 (07) 773-777
    CrossrefPubMedGoogle Scholar
  • 11 Rankin GB, Watts HD, Melnyk CS, Kelley Jr ML. National Cooperative Crohn's Disease Study: extraintestinal manifestations and perianal complications. Gastroenterology 1979; 77 (4 Pt 2): 914-920
    CrossrefPubMedGoogle Scholar
  • 12 Schwartz DA, Loftus Jr EV, Tremaine WJ. et al. The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota. Gastroenterology 2002; 122 (04) 875-880
    CrossrefPubMedGoogle Scholar
  • 13 Fields S, Rosainz L, Korelitz BI, Panagopoulos G, Schneider J. Rectal strictures in Crohn's disease and coexisting perirectal complications. Inflamm Bowel Dis 2008; 14 (01) 29-31
    CrossrefPubMedGoogle Scholar
  • 14 Alli-Akintade L, Pruthvi P, Hadi N, Sachar D. Race and fistulizing perianal Crohn's disease. J Clin Gastroenterol 2015; 49 (03) e21-e23
    CrossrefPubMedGoogle Scholar
  • 15 Beaugerie L, Carrat F, Nahon S. et al; Cancers et Surrisque Associé aux Maladies Inflammatoires Intestinales En France Study Group. High risk of anal and rectal cancer in patients with anal and/or perianal Crohn's disease. Clin Gastroenterol Hepatol 2018; 16 (06) 892-899.e2
    CrossrefPubMedGoogle Scholar
  • 16 Ky A, Sohn N, Weinstein MA, Korelitz BI. Carcinoma arising in anorectal fistulas of Crohn's disease. Dis Colon Rectum 1998; 41 (08) 992-996
    CrossrefPubMedGoogle Scholar
  • 17 Gaertner WB, Hagerman GF, Finne CO. et al. Fistula-associated anal adenocarcinoma: good results with aggressive therapy. Dis Colon Rectum 2008; 51 (07) 1061-1067
    CrossrefPubMedGoogle Scholar
  • 18 Devon KM, Brown CJ, Burnstein M, McLeod RS. Cancer of the anus complicating perianal Crohn's disease. Dis Colon Rectum 2009; 52 (02) 211-216
    CrossrefPubMedGoogle Scholar
  • 19 Yang BL, Shao WJ, Sun GD, Chen YQ, Huang JC. Perianal mucinous adenocarcinoma arising from chronic anorectal fistulae: a review from single institution. Int J Colorectal Dis 2009; 24 (09) 1001-1006
    CrossrefPubMedGoogle Scholar
  • 20 Lad SV, Haider MA, Brown CJ, Mcleod RS. MRI appearance of perianal carcinoma in Crohn's disease. J Magn Reson Imaging 2007; 26 (06) 1659-1662
    CrossrefPubMedGoogle Scholar
  • 21 Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg 1976; 63 (01) 1-12
    CrossrefPubMedGoogle Scholar
  • 22 Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB. American Gastroenterological Association Clinical Practice Committee. AGA technical review on perianal Crohn's disease. Gastroenterology 2003; 125 (05) 1508-1530
    CrossrefPubMedGoogle Scholar
  • 23 Panes J, Bouhnik Y, Reinisch W. et al. Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohn's Colitis 2013; 7 (07) 556-585
    CrossrefPubMedGoogle Scholar
  • 24 Morris J, Spencer JA, Ambrose NS. MR imaging classification of perianal fistulas and its implications for patient management. Radiographics 2000; 20 (03) 623-635 , discussion 635–637
    CrossrefPubMedGoogle Scholar
  • 25 Allan A, Linares L, Spooner HA, Alexander-Williams J. Clinical index to quantitate symptoms of perianal Crohn's disease. Dis Colon Rectum 1992; 35 (07) 656-661
    CrossrefPubMedGoogle Scholar
  • 26 Present DH, Rutgeerts P, Targan S. et al. Infliximab for the treatment of fistulas in patients with Crohn's disease. N Engl J Med 1999; 340 (18) 1398-1405
    CrossrefPubMedGoogle Scholar
  • 27 Van Assche G, Vanbeckevoort D, Bielen D. et al. Magnetic resonance imaging of the effects of infliximab on perianal fistulizing Crohn's disease. Am J Gastroenterol 2003; 98 (02) 332-339
    CrossrefPubMedGoogle Scholar
  • 28 Ng SC, Plamondon S, Gupta A. et al. Prospective evaluation of anti-tumor necrosis factor therapy guided by magnetic resonance imaging for Crohn's perineal fistulas. Am J Gastroenterol 2009; 104 (12) 2973-2986
    CrossrefPubMedGoogle Scholar
  • 29 Maconi G, Greco MT, Asthana AK. Transperineal ultrasound for perianal fistulas and abscesses—a systematic review and meta-analysis. Ultraschall Med 2017; 38 (03) 265-272
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Sahni VA, Ahmad R, Burling D. Which method is best for imaging of perianal fistula?. Abdom Imaging 2008; 33 (01) 26-30
    CrossrefPubMedGoogle Scholar
  • 31 Siddiqui MR, Ashrafian H, Tozer P. et al. A diagnostic accuracy meta-analysis of endoanal ultrasound and MRI for perianal fistula assessment. Dis Colon Rectum 2012; 55 (05) 576-585
    CrossrefPubMedGoogle Scholar
  • 32 Lee T, Yong E, Ding NS. Radiological outcomes in perianal fistulizing Crohn's disease: a systematic review and meta-analysis. JGH Open 2019; 4 (03) 340-344
    CrossrefPubMedGoogle Scholar
  • 33 Deckers IE, Benhadou F, Koldijk MJ. et al. Inflammatory bowel disease is associated with hidradenitis suppurativa: results from a multicenter cross-sectional study. J Am Acad Dermatol 2017; 76 (01) 49-53
    CrossrefPubMedGoogle Scholar
  • 34 Yadav S, Singh S, Edakkanambeth Varayil J. et al. Hidradenitis suppurativa in patients with inflammatory bowel disease: a population-based cohort study in Olmsted County, Minnesota. Clin Gastroenterol Hepatol 2016; 14 (01) 65-70
    CrossrefPubMedGoogle Scholar
  • 35 Monnier L, Dohan A, Amara N. et al. Anoperineal disease in Hidradenitis Suppurativa: MR imaging distinction from perianal Crohn's disease. Eur Radiol 2017; 27 (10) 4100-4109
    CrossrefPubMedGoogle Scholar
  • 36 Braveman JM, Schoetz Jr DJ, Marcello PW. et al. The fate of the ileal pouch in patients developing Crohn's disease. Dis Colon Rectum 2004; 47 (10) 1613-1619
    CrossrefPubMedGoogle Scholar
  • 37 Melton BG, Fazio VW, Kiran RP. et al. Long-Term outcomes with ileal pouch-anal anastomosis and Crohnʼs disease. Ann Surg 2008; 248 (04) 608-616
    CrossrefPubMedGoogle Scholar
  • 38 Lightner AL, Pemberton JH, Loftus Jr EJ. Crohn's disease of the ileoanal pouch. Inflamm Bowel Dis 2016; 22 (06) 1502-1508
    CrossrefPubMedGoogle Scholar
  • 39 Tekkis PP, Heriot AG, Smith O, Smith JJ, Windsor AC, Nicholls RJ. Long-term outcomes of restorative proctocolectomy for Crohn's disease and indeterminate colitis. Colorectal Dis 2005; 7 (03) 218-223
    CrossrefPubMedGoogle Scholar
  • 40 Reza LM, Lung PFC, Lightner AL, Hart AL, Clark SK, Tozer PJ. Perianal fistula and the ileoanal pouch—different aetiologies require distinct evaluation. Colorectal Dis 2020; 22 (10) 1436-1439
    CrossrefPubMedGoogle Scholar
  • 41 Hartley JE, Fazio VW, Remzi FH. et al. Analysis of the outcome of ileal pouch-anal anastomosis in patients with Crohn's disease. Dis Colon Rectum 2004; 47 (11) 1808-1815
    CrossrefPubMedGoogle Scholar
  • 42 Goldstein NS, Sanford WW, Bodzin JH. Crohn's-like complications in patients with ulcerative colitis after total proctocolectomy and ileal pouch-anal anastomosis. Am J Surg Pathol 1997; 21 (11) 1343-1353
    CrossrefPubMedGoogle Scholar