Fistulae Management

Currently, there are no data supporting the role of endoscopy as primary treatment of fistulising Crohn's disease. Nevertheless, aside from guiding medical and surgical therapy of a fistula, endoscopy may indirectly and directly impact the treatment of fistulising Crohn's disease [58]. Indirectly, endoscopy may allow for dilation of obstructing strictures that prevent the closure of the fistula. Directly, may treat the fistula via an injection of fibrin-based sealants or anticytokine therapy. A fistula located proximal to an obstructive stricture does not heal due to an increase in luminal pressure. Endoscopic balloon dilation of the stricture would reduce intra-luminal pressure and the amount of bowel contents passing through the fistula, and allow for a better chance of closure. For endoscopic dilation to be successful, the stricture must be accessible, short (<8 cm) and not significantly inflamed, conditions that are often not the present in fistulising Crohn's disease. Nevertheless, in a patient with a symptomatic fistula that is proximal to a short, noninflammatory stricture, endoscopic balloon dilation offers an alternative to surgery.

There are case reports of injecting fibrin tissue sealant into a perineal fistula of patients with IBD [59]. Results of an external fistula closure with fibrin sealants are disappointing. Recently, there have been several reports on the endoscopic treatment of a gastrointestinal fistula with various tissue sealants as fibrin-based, collagen or amino-acid solutions [60,61]. However, these reports were not related to IBD but to fistulas secondary to other diseases, and endoscopi-cally administered tissue sealants are unlikely to play a role in the treatment of Crohn's disease fistulas [62]. To date there are no studies that have evaluated the role of endoscopically administered biologic therapy for treatment of Crohn's fistula, and there is only one published abstract that has evaluated local injection of infliximab into a perianal fistula. As new therapies becomes available, there will be a greater need for therapy administered directly to the mucosa, and therapeutic endoscopy may play a role in the treatment of fistulising Crohn's disease. One study was performed using EUS to assess and guide combination medical and surgical therapy for patients with Crohn's perianal fistulas [63]. The presence of fistula healing on EUS was used to guide seton removal and discontinuation of infliximab or antibiotics, demonstrating that EUS may identify a subset of patients who can discontinue infliximab without recurrence of fistula drainage.

Although there are no reports of stricture dilation in Crohn's disease patients with ileal or colonic stomas, the same principles as with ileocolonic or colonic strictures apply [51]. Endoscopic management of these strictures may be more desirable in many of these patients who have already undergone multiple bowel resections. Radiologic contrast imaging and endoscopy will provide information on whether the stricture is amenable to hydrostatic balloon dilation. The procedure may be repeated with progressively larger-diameter balloons until a satisfactory result is obtained, such as being able to pass a standard colonoscope through the stricture. Contraindications to dilation include coagulopathy and strictures associated with large and deep ulcerations.

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