Penetrating Crohn's disease

Penetrating Crohn's Disease

Crohn's disease can result in disruption of intestinal integrity. This can allow luminal contents to migrate into the abdominal cavity, resulting in an abscess; or result in a fistula, namely an abnormal connection between segments of intestine (entero-enteric fistula), or between a segment of intestine and another organ (e.g. entero-vesical or entero-vaginal fistula), or between a segment of intestine and the abdominal wall (entero-cutaneous fistula). The latter often arise in the perianal area (perianal Crohn's disease).

The principles of management of fistula are:

  • Locate the origin and anatomy of the fistula
  • Determine which organs are affected
  • Exclude local abscess; treat sepsis if present
  • Evaluate whether the originating intestinal loop is inflamed and/or stenosed
  • Assess patient's nutritional state
  • Plan surgery if appropriate

There is very little controlled data hence advice is mainly based on expert opinion.

Considerations prior to treatment

Exclude sepsis; correct fluid and electrolyte disturbance

 

  • Fistula usually assessed using cross-sectional imaging
  • MRI preferred, where possible, over CT to avoid radiation burden
Establish anatomy

  • Multidisciplinary team management required, led by gastroenterologist and colorectal surgeon
  • Refer complex disease to specialist centre
Enterocutaneous fistula

ECCO statement 9N (CD 2016)

Enteroenteric and enterovesical fistulae often require resective surgery [EL5]. Surgery is strongly recommended for enteroenteric fistulas if associated with abscess and bowel stricture and if they cause excessive diarrhea and malabsorption [EL5]

Further information

  • Regularly screen patients with enterovesical fistula for urinary tract infection
Enterovesical and enteroenteric fistula

Enterogynaecological fistula

Perianal fistula

Intra-abdominal abscess

Intra-abdominal abscess

  • Multidisciplinary team management required with gastroenterologist, interventional radiologist and colorectal surgeon
  • Interventional radiological drainage and intravenous antibiotics usually first line therapy
Antibiotics, and radiological or surgical drainage

  • Patients with overt sepsis should be “nil by mouth” initially
  • Consider complete bowel rest and intra-venous nutrition in those who relapse when enteral nutrition reintroduced
Optimise medical therapy and nutrition

  • “Early” surgery after ≈ 2-3 weeks medical therapy required if symptomatic and objective improvement slow; or in those with associated fibro-stenotic disease
Consider delayed surgery

Enterocutaneous

Enterocutaneous fistula

 

Assess symptoms

 

  • High output fistula (> 1L/d) rare unless iatrogenic (post-surgical), often associated with short bowel syndrome
  • Limit oral intake to 1 L/d iso-osmolar solution (e.g. St. Mark's solution) and replace fluid losses
  • Try a combination of loperamide, codeine phosphate and proton pump inhibitor to reduce output
  • Liaise with specialist centre, especially if high output does not resolve within 1-2 weeks
IV hydration +/- IV nutrition

 

Oral hydration and nutrition

 

Non-troublesome symptoms

Troublesome symptoms

 

Optimise medical therapy and nutrition

  • Active disease usually defined by raised serological markers (CRP) and/or active mucosal disease (assessed endoscopically)
Active disease

Inactive disease

 

  • Medical therapies include immunomodulators and anti-TNF. The best, albeit very limited evidence supports using anti-TNF in internal or enterocutaneous fistulas
Optimise nutrition;
trial of medical therapy

 
 

Maintain optimal medical therapy

  • Avoid “early” surgery in the mal-nourished patient, which is associated with fistula recurrence and complications. Surgery usually delayed for 3-6 months after fistula formation, to allow for inflammation resolution and improvement in nutritional status
Optimise nutrition;
Surgery

Enterovesical & enteroenteric

ECCO statement 9N (CD 2016)

Enteroenteric and enterovesical fistulae often require resective surgery [EL5]. Surgery is strongly recommended for enteroenteric fistulas if associated with abscess and bowel stricture and if they cause excessive diarrhea and malabsorption [EL5]

Further information

  • Regularly screen patients with enterovesical fistula for urinary tract infection
Enterovesical and enteroenteric fistula

 

Assess symptoms

 

Non-troublesome symptoms

Troublesome symptoms

 

Optimise medical therapy and nutrition

  • Active disease usually defined by raised serological markers (CRP) and/or active mucosal disease (assessed endoscopically)
Active disease

Inactive disease

 

  • Medical therapies could include immunomodulators and anti-TNF. There is no evidence base on which to make recommendations
  • Most patients are treated surgically, though a 3 month trial of anti-TNF is appropriate, particularly in patients in whom it is indicated for more widespread disease
Optimise nutrition;
possible trial of medical therapy

 
 

Maintain optimal medical therapy

Optimise nutrition;
Surgery

Enterogynaecological

Enterogynaecological fistula

 

Assess symptoms

 

Non-troublesome symptoms

Troublesome symptoms

 

ECCO statement 9O (CD 2016)

Asymptomatic low anal-introital fistulae do not need surgical treatment [EL5]. If a patient has a symptomatic rectovaginal fistula, surgery is usually necessary (including diverting ostomy) [EL5]. Active CD with rectal inflammation should be treated medically prior to surgery and after surgery to prevent recurrence [EL5]

Symptomatic therapy;
optimise nutrition

  • Active disease usually defined by raised serological markers (CRP) and/or active mucosal disease (assessed endoscopically)
Active disease

Inactive disease

 

ECCO statement 9O (CD 2016)

Asymptomatic low anal-introital fistulae do not need surgical treatment [EL5]. If a patient has a symptomatic rectovaginal fistula, surgery is usually necessary (including diverting ostomy) [EL5]. Active CD with rectal inflammation should be treated medically prior to surgery and after surgery to prevent recurrence [EL5]

Further information

  • Consider medical therapy prior to surgery especially in those with rectal inflammation
  • Of 25 patients in ACCENT II trial with rectovaginal fistulae, 45% were closed at 14 weeks
  • There is no controlled data for other medical therapies
  • Symptomatic fistula arising from the small bowel or sigmoid colon usually require resection of diseased intestinal segment
Optimise nutrition;
trial medical therapy

 
 

Maintain optimal medical therapy

ECCO statement 9O (CD 2016)

Asymptomatic low anal-introital fistulae do not need surgical treatment [EL5]. If a patient has a symptomatic rectovaginal fistula, surgery is usually necessary (including diverting ostomy) [EL5]. Active CD with rectal inflammation should be treated medically prior to surgery and after surgery to prevent recurrence [EL5]

Further information

  • Surgery is usually necessary for enterogynaecological fistula
  • Procedures include an advancement flap, gracilis muscle interposition or diverting ‘ostomy when symptoms intolerable. Reasonable outcomes are obtainable in ≈ 50%
  • There is insufficient evidence to support routine use of fistula plugs / glue
  • Avoid high dose peri-operative systemic corticosteroid therapy
Optimise nutrition;
Surgery

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