Perianal Crohn’s disease: Is there something new?

Traitement des fistules anales réfractaires à l’Infliximab au cours de la maladie de Crohn : Mise au point

INTRODUCTION

Treatment of complex perianal fistulas in Crohn's disease remains a challenge especially after the failure of Infliximab.

AIM

Update on the different therapeutic alternatives for anal fistula in Crohn's disease after failure of Infliximab.

METHODS

A research in the medical literature on PubMed and Google Scholar was carried out. We included cohort studies, reviews and randomized double-blinded therapeutic trials. Case reports and fundamental research studies have been excluded.

RESULTS

Anti-TNF therapy, notably Infliximab remain the therapeutic option of choice. Since Infliximab efficacy has been estimated at 60%, with a significant loss-of response rate, new therapeutic strategies have been evaluated and may offer new opportunities for the management of anal fistulas: for example, Ustekinumab could be effective after failure of anti-TNF therapy, although further studies are required. Recent guidelines suggest that injection of mesenchymal stem cells is an effective and safe treatment for complex fistulas. Other surgical options have been proposed, such as endorectal advancement flap, fibrin glue injection, anal fistula plug and ligation of the intersphincteric fistula tract, but all with limited and debatable efficacy. Given the failure rate of all these options, new strategies are currently being evaluated.

CONCLUSION

Anal fistulas in Crohn's disease are a real therapeutic challenge. New medical and surgical therapies are currently being evaluated, with promising results.

Medical and surgical management of perianal Crohn's disease

Crohn's disease is increasingly thought to encompass multiple possible phenotypes. Perianal manifestations account for one such phenotype and represent an independent disease modifier. In its more severe form, perianal Crohn's disease confers a higher risk of a severe and disabling disease course, relapses, hospital admissions and operations. This, in turn, imposes a considerable burden and disability on patients. Identification of the precise manifestation is important, as management is nuanced, with both medical and surgical components, and is best undertaken in a multidisciplinary setting for both diagnosis and ongoing treatment. The introduction of biologic medication has heralded a significant addition to the management of fistulizing perianal Crohn's disease in particular, albeit with modest results. It remains a very challenging condition to treat and further work is required to optimize management in this group of patients.

Role of ultrasound in colorectal diseases

Ultrasound is an undervalued non-invasive examination in the diagnosis of colonic diseases. It has been replaced by the considerably more expensive magnetic resonance imaging and computed tomography, despite the fact that, as first examination, it can usefully supplement the diagnostic process. Transabdominal ultrasound can provide quick information about bowel status and help in the choice of adequate further examinations and treatment. Ultrasonography, as a screening imaging modality in asymptomatic patients can identify several colonic diseases such as diverticulosis, inflammatory bowel disease or cancer. In addition, it is widely available, cheap, non-invasive technique without the use of ionizing radiation, therefore it is safe to use in childhood or during pregnancy, and can be repeated at any time. New ultrasound techniques such as elastography, contrast enhanced and Doppler ultrasound, mini-probes rectal and transperineal ultrasonography have broadened the indication. It gives an overview of the methodology of various ultrasound examinations, presents the morphology of normal bowel wall and the typical changes in different colonic diseases. We will pay particular attention to rectal and transperineal ultrasound because of their outstanding significance in the diagnosis of rectal and perineal disorders. This article seeks to overview the diagnostic impact and correct indications of bowel ultrasound.

Perianal complete remission with combined therapy (seton placement and anti-TNF agents) in Crohn's disease: a Brazilian multicenter observational study

BACKGROUND

Perianal fistulizing Crohn's disease is one of the most severe phenotypes of inflammatory bowel diseases. Combined therapy with seton placement and anti-TNF therapy is the most common strategy for this condition.

OBJECTIVES

The aim of this study was to analyze the rates of complete perianal remission after combined therapy for perianal fistulizing Crohn's disease.

METHODS

This was a retrospective observational study with perianal fistulizing Crohn's disease patients submitted to combined therapy from four inflammatory bowel diseases referral centers. We analyzed patients' demographic characteristics, Montreal classification, concomitant medication, classification of the fistulae, occurrence of perianal complete remission and recurrence after remission. Complete perianal remission was defined as absence of drainage from the fistulae associated with seton removal.

DISCUSSION

A total of 78 patients were included, 44 (55.8%) females with a mean age of 33.8 (±15) years. Most patients were treated with Infliximab, 66.2%, than with Adalimumab, 33.8%. Complex fistulae were found in 52/78 patients (66.7%). After a medium follow-up of 48.2 months, 41/78 patients (52.6%) had complete perianal remission (95% CI: 43.5%-63.6%). Recurrence occurred in four (9.8%) patients (95% CI: 0.7%-18.8%) in an average period of 74.8 months.

CONCLUSIONS

Combined therapy lead to favorable and durable results in perianal fistulizing Crohn's disease.

Factors affecting the fate of faecal diversion in patients with perianal Crohn's disease

AIM

A study was carried out with the aim of identifying potential factors which might influence the fate of patients undergoing faecal diversion by stoma in perianal Crohn's disease.

METHOD

Patients with severe perianal Crohn's disease undergoing faecal diversion between 1994 and 2012 were identified and the factors associated with stoma closure were assessed using univariate and multivariate analysis.

RESULTS

Of 138 diverted patients, 30 (22%) achieved stoma closure, 45 (33%) had a stoma with the rectum left in situ and 63 (45%) underwent proctectomy with permanent stoma formation after a mean follow-up of 5.7 years. Univariate analysis demonstrated that synchronous colonic (P = 0.004) or rectal (P = 0.021) disease involvement and an increased frequency of loose seton placement (P = 0.001) adversely affected successful stoma closure rates. Multivariate analysis indicated a significant association between the inability to achieve stoma closure and persisting rectal involvement (OR 7.5, 95% CI 2.4-33.4), one or two placements of a loose seton (OR 3.3, 95% CI 1.4-8.8) and more than two placements (OR 6.9, 95% CI 1.2-132.5). No specific medical management was associated with an improved stoma closure rate, including biological agents when these were available (P = 0.25).

CONCLUSION

The fate of temporary faecal diversion in patients with perianal Crohn's disease is adversely affected by aggressive disease characteristics. No particular treatment, including biological therapy, was associated with an improved outcome.

Anorectal complications and function in patients suffering from inflammatory bowel disease: a series of patients with long-term follow-up

AIM

The aim of this study is to describe the long-term course of anorectal complains and function in a single centre cohort patients suffering from inflammatory bowel disease (IBD) with perianal lesions.

METHODS

Between 1993 and 2000, 56 IBD patients (43 Crohn's disease and 13 ulcerative colitis) with perianal complaints underwent anorectal function evaluation (AFE) (baseline). For follow-up, they were approached between 2010 and 2012 by sending questionnaires including Inflammatory Bowel Disease Quality of Life Questionnaire (IBDQ), Perianal Disease Activity Index (PDAI), faecal incontinence scale (Vaizey) and an invitation for AFE.

RESULTS

At follow-up, 46 patients (82 %) were available, 9 (16 %) were lost and 1 (2 %) had died. Thirty patients returned the questionnaires of which 17 also underwent AFE. The remaining 16 patients were interviewed by phone and were only willing to mention their anorectal complaints. Median follow-up was 14 year. In 25 of the 46 patients (54 %), perianal complaints persisted faecal incontinence (n = 7); soiling (n = 13) and active fistula (n = 5). Eighteen (39 %) patients had an active fistula at baseline and three persisted at follow-up. Two developed a new fistula. Mean IBDQ, Vaizey and PDAI were 178 (SD 29), 7 (SD 5) and 4.2 (SD 3.0), respectively. In 17 patients, who underwent AFE, anal endosonography showed healing in nine of the ten fistulas. Anal pressures as well as rectal capacity remained unaltered in the individual patient, but showed a large range within the group.

CONCLUSION

After 14 years, 54 % of the IBD patients with perianal lesions still have mild complaints. The quality of life remained moderate over a long period, which is concerning.

Recent developments in the surgical management of perianal fistula for Crohn's disease

Perianal manifestations of Crohn's disease (CD) are common and, of them, fistulas are the most common. Perianal fistulas can be extremely debilitating for patients and are often very challenging for clinicians to treat. CD perianal fistulas usually require multidisciplinary and multimodality treatment, including both medical and surgical approaches. The majority of patients require multiple surgical interventions. CD patients with perianal fistulas have a high rate of primary non-healing, surgical morbidity, and high recurrence rates. This has led to constant efforts to improve surgical management of this disease process.

Crohn's disease in women

This article provides an overview of the obstetric and gynecological manifestations of Crohn's disease (CD). High incidence of the new onset of the disease in young women in their reproductive years demands special concern from physicians involved in their treatment. Pregnant women with CD are considered high-risk patients, regardless of disease activity index, due to associated complications. Predominately described complications are premature birth, low birth weight, and congenital anomalies. To minimize the risk for adverse pregnancy/birth outcomes, it is recommended that remission be achieved before conception. Treatment of CD in pregnant women is similar to that among the nonpregnant population, and there is no valid reason to terminate it, since most of the drugs are proven to be safe. Women with CD who wish to conceive or are already pregnant need to be properly advised according to the newest guidelines on the subject, given by the European Crohn's and Colitis Organization. Gynecological manifestations are another special feature of CD. They are important in that they may facilitate early recognition of the underlying disease, which usually stays unrecognized for years before intestinal manifestation; in this way, the underlying manifestations are often mistreated.

Anorectal fistula is an early manifestation of Crohn's disease that occurs before bowel lesions advance: a study of 11 cases

The diagnostic significance of single-balloon enteroscopy (SBE) in patients presenting with Crohn's disease (CD)-like anorectal fistula is unknown. We experienced 11 cases undergoing SBE due to CD-like fistulas between December 2007 and April 2013. The mean interval from fistula onset to SBE was 19.2 months with a range of 1.3-44.7. Prior to SBE, all patients underwent anorectal examination under anesthesia (EUA), and 9 patients underwent total colonoscopy with terminal ileal cannulation (TCS-I). One of 7 patients undergoing upper gastrointestinal endoscopy had CD-like gastritis. EUA revealed CD fissures in 7 patients, 1 of whom had no intestinal lesion. Primary TCS-I identified early lesions, such as aphthes and small ulcers, in 4 patients. Among the other 5 patients without any intestinal lesions with TCS-I, SBE indicated early lesions in 3 patients. One of 2 patients who initially underwent SBE without TCS-I showed multiple aphthes. Of the 11 patients, only 4 patients fulfilled the definitive Japanese diagnostic criteria for CD and 7 remained 'suspected CD' cases. Intrinsic anorectal fistulas as a presenting symptom of CD may be an early predictor of bowel lesions. SBE has the potential to reveal incipient disease because an early ileal lesion is not rare for patients with anorectal fistulas.

The evaluation and treatment of Crohn perianal fistulae: EUA, EUS, MRI, and other imaging modalities

Perianal fistulizing disease is a common complication of CD that requires a multidisciplinary collaboration between gastroenterology, surgery, and radiology professionals for successful assessment and treatment. Optimal success comes from a combined medical and surgical approach to treat the fistulizing disease (see Fig. 1). Unfortunately, even with a variety of surgical options, a subset of patients require permanent fecal diversion and/or proctectomy to successfully treat their disease. Further studies (likely requiring large, multicenter trials) of novel medical and surgical treatments are still warranted to formulate optimal management of this complex condition.