Fistulating perianal disease

Fistulating perianal disease

Sepsis suggested by:

  • perianal pain on rectal examination
  • and/or fever
  • and/or localised mass/erythema
  • and/or recent inflammatory marker rise
Is sepsis present?

ECCO statement 9A (CD 2016)

Contrast-enhanced pelvic magnetic resonance imaging (MRI) is considered the initial procedure for the assessment of perianal fistulising CD [EL2]. If rectal stenosis is excluded, endoscopic anorectal ultrasound (EUS) is a good alternative [EL2]. The specificity and sensitivity of both imaging modalities is increased when combined with examination under anaesthetic (EUA) [EL1]. Fistulography is not recommended [EL3]. If a perianal fistula is detected, EUA is considered the gold standard in the hands of an experienced surgeon [EL5]

Further information

  • Start appropriate antibiotics
  • AGA recommends MRI prior to surgery, to prevent erroneous fistulotomy with a high fistula
  • ECCO guideline stresses strongly that EUA must not be delayed as sepsis can be destructive
  • EUA allows sepsis to be drained and a seton placed if required
  • Endoscopy (colonoscopy if proximal colon never reviewed or needs re-review) determines if treatment required for mucosal disease
Urgent EUA (experienced surgeon) ideally with prior pelvic MRI

 

ECCO statement 9A (CD 2016)

Contrast-enhanced pelvic magnetic resonance imaging (MRI) is considered the initial procedure for the assessment of perianal fistulising CD [EL2]. If rectal stenosis is excluded, endoscopic anorectal ultrasound (EUS) is a good alternative [EL2]. The specificity and sensitivity of both imaging modalities is increased when combined with examination under anaesthetic (EUA) [EL1]. Fistulography is not recommended [EL3]. If a perianal fistula is detected, EUA is considered the gold standard in the hands of an experienced surgeon [EL5]

ECCO statement 9B (CD 2016)

Since the presence of concomitant rectosigmoid inflammation has prognostic and therapeutic relevance, proctosigmoidoscopy should be used routinely in the initial evaluation [EL2]

Further information

  • Pelvic MRI defines anatomical abnormalities
  • Endoscopy (colonoscopy if proximal colon never reviewed or needs re-review) determines if treatment required for mucosal disease
  • Provide empiric treatment (antibiotics) if investigations delayed
Pelvic MRI and flexible sigmoidoscopy; consider colonoscopy

ECCO statement 9C (CD 2016)

There is no consensus for classifying perianal fistulae in CD. In clinical practice most experts use a classification of simple or complex [EL5]

ECCO statement 9D (CD 2016)

Pelvic floor dysfunction can be addressed in individual patients and in cases of severe impairment a specific rehabilitation program is recommended [EL4]

Further information

  • Healing rates are lower in those with rectal inflammation
  • Anti-TNF reduces surgery rates
Classify type of perianal disease

ECCO statement 9F (CD 2016)

Symptomatic simple perianal fistulae require treatment. Seton placement in combination with antibiotics (metronidazole and/or ciprofloxacin) is the preferred strategy [EL3]. In recurrent refractory simple fistulising disease not responding to antibiotics, thiopurines or anti-TNFs can be used as second line therapy [EL4]

Further information

  • No treatment is needed if the simple fistula is asymptomatic, assuming there is no disease elsewhere
  • If so, re-assess the patient in approximately 4 months
Is it symptomatic?

 
 

ECCO statement 9E (CD 2016)

In an uncomplicated low anal fistula, simple fistulotomy may be discussed [EL5]. The presence of a perianal abscess should be ruled out and if present should be drained [EL5]

Further information

  • Prognostic factors and disease extent will help determine which therapies are used
  • The AGA recommends that treatment with azathioprine should also be considered
Treat with metronidazole or ciprofloxacin; consider EUA for seton placement or fistulotomy

 

ECCO statement 9G (CD 2016)

Seton placement after surgical treatment of sepsis is recommended for complex fistulae [EL2]. The timing of removal depends on subsequent therapy

ECCO statement 9H (CD 2016)

Active luminal Crohn’s disease should be treated if present, in conjunction with appropriate surgical management of fistulae [EL5]

ECCO statement 9I (CD 2016)

In complex perianal fistulising disease infliximab [EL1] or adalimumab [EL2] can be used as first line therapy following adequate surgical drainage if indicated. A combination of ciprofloxacin and anti-TNF improves short term outcomes [EL1]. To enhance the effect of anti-TNF in complex fistulising disease, combination of anti-TNF treatment with thiopurines may be considered (EL5]

Further information

  • Consider anti-TNF if poor prognostic features or failure to respond to induction therapy
Treat with ciprofloxacin, usually then with anti-TNF +/- thiopurine; perform EUA to drain abscess, place non-cutting seton

ECCO statement 9K (CD 2016)

In evaluating the response to medical or surgical treatment in routine practice, clinical assessment (decreased drainage) is usually sufficient [EL2]. MRI [EL2] or anal endosonography [EL3] in combination with clinical assessment is recommended to evaluate the improvement of fistula track inflammation [EL5]

Further information

Response defined by > 50% reduction in drainage with gentle digital pressure

Perform clinical assessment at least every 3 months

 

ECCO statement 9K (CD 2016)

In evaluating the response to medical or surgical treatment in routine practice, clinical assessment (decreased drainage) is usually sufficient [EL2]. MRI [EL2] or anal endosonography [EL3] in combination with clinical assessment is recommended to evaluate the improvement of fistula track inflammation [EL5]

Perform clinical assessment at least every 3 months

 

Assess every 4-6 months; perform MRI +/- endoscopy at 12 months

 

  • Occasionally non-healing will eventually require proctectomy
  • Healing rates are lower in those with rectal inflammation for whom a non-cutting seton and intensive medical therapy is preferred
  • Repeat MRI if poor response despite treatment escalation; and consider fistulotomy
Consider metronidazole, thiopurine, anti-TNF

ECCO statement 9L (CD 2016)

Thiopurines [EL2], infliximab [EL1] or adalimumab [EL2], seton drainage, or a combination of drainage and medical therapy [EL3] should be used as maintenance therapy

Further information

  • The duration of seton drainage is not established, but required long-term in some patients
Assess every 4 to 6 months

ECCO statement 9K (CD 2016)

In evaluating the response to medical or surgical treatment in routine practice, clinical assessment (decreased drainage) is usually sufficient [EL2]. MRI [EL2] or anal endosonography [EL3] in combination with clinical assessment is recommended to evaluate the improvement of fistula track inflammation [EL5]

ECCO statement 9I (CD 2016)

In complex perianal fistulising disease infliximab [EL1] or adalimumab [EL2] can be used as first line therapy following adequate surgical drainage if indicated. A combination of ciprofloxacin and anti-TNF improves short term outcomes [EL1]. To enhance the effect of anti-TNF in complex fistulising disease, combination of anti-TNF treatment with thiopurines may be considered (EL5]

Further information

  • Maintenance anti-TNF has been shown to reduce hospitalistion and surgery
  • Consider if poor prognostic features or failure to respond to induction therapy
  • Treat active luminal disease
  • Anti-TNF has been proven to reduce inflammation and heal peri-anal Crohn’s fistula
  • Ongoing inflammation results in irreversible tissue destruction and can lead to incontinence later in life
Perform clinical assessment at least every 3 months; consider addition of anti-TNF

 
 

ECCO statement 9M (CD 2016)

Patients refractory to medical treatment should be considered for a diverting ostomy, with proctectomy as the last resort [EL5]

Further information

Options could include:

  • Anti-TNF modification
    • Optimizing anti-TNF dosing
    • Stopping anti-TNF therapy, e.g. if no primary response
    • Switching anti-TNF therapies
  • Alternative medical therapies
    • trial therapies
    • Tacrolimus
    • Mycophenalalte, G-CSF, MTX, Thalidomide, Hyperbaric O2
  • Surgical therapies
    • Ongoing seton use
    • Diversion stoma
    • Proctectomy
Perform MRI +/- endoscopy to exclude complications. Modify anti-TNF treatment (optimize dose, switch) or switch to immunomodulators & antibiotics. Consider diverting stoma

 

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