Recto Vaginal Fistula

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The development of fistulae is a common complication of Crohn's disease (CD). The lifetime risk of fistula development in patients with CD has typically been reported to range from 20 to 40%. The reported incidence of fistulizing CD from referral-based case series ranged from 17% to as much as 85% [1-3]. The probability of internal fistulae was particularly high in patients with perianal disease who presented a relative risk of 3.4 compared to patients with different localizations [4].

Over time, many fistulae tend to heal. As for example, in a cohort of 87 patients [5] with external fistulae, from the time of first presentation (involvement ileo-colonic or colonic in 85% of cases, rectal in 65% of cases), after a median follow-up of 5.9 years, 68% showed healing of all fistulae, whereas in the remaining patients, partial or no healing was evident. Ninety-four percent of simple perianal fistulae were healed by the final visit compared with 70% of the complex perianal fistulae. Rectovaginal (median 26 months), enteroen-teric (9.4 months) and abdominal wall (6.3 months) took a significantly shorter time to heal compared to perianal fistulae, either simple (44 months) or complex (42.8 months); there was no difference in healing time among complex and simple perianal fistulae.

Table 1 shows the outcome of current medical and surgical treatment in patients with different types of fistulae. It appears that medical treatment only has marginal efficacy with a failure rate of almost 90%. Even surgery has a high rate of effectiveness only in perianal disorders, whereas in the remaining locations, most patients do not respond and therefore require complex procedures (resection, defunction-ating stoma, proctectomy).

In a longitudinal study of fistulizing CD in patients from Olmestead County, at least one fistula occurred in 35% of the patients, and at least one perianal fistula occurred in 20% [6]. The fistula developed before the diagnosis in 20% of cases and at the diagnosis in 29% of cases; in the remaining patients, the onset of fistulae was delayed (median time from the diagnosis to the first fistula was 5.5 years). The risk of fistulae was very high in the first year, and then it progressively increased over the following 20 years to a value of 50% for all locations and 26% for perianal lesions [7].

The clinical consequences of the fistulous tract depend on the nature of the adjacent tissues, the origin and the terminus of the fistula and the infectious process resulting from transit of enteric microorganisms through the fistula. In perianal fistulae, identification of specific routes created by fistula tracts informs prognostic and therapeutic options.

Patients with painful perianal fistula and associated abscess formations require surgical drainage, seton placement, and, in severe cases, proctectomy (Fig. 1). In contrast, patients with asymptomatic internal fistula require no intervention.

A variety of surgical and medical measures to induce healing of external fistulae has been proposed, but a comparison of their relative merits is difficult. This is due in part to different criteria used

Table 1. Efficacy of standard medical and of routine surgical treatments in different types of Crohn's disease fistulae, and the percent of patients requiring more complex surgical intervention [5]

Perianal Rectovaginal Internal Abdominal

Simple Complex wall

Efficacy of medical treatment 9 13 13.5 8 7

Efficacy of simple surgery 82 47 13.5 8 13

Need of complex surgery 6 38 13.5 84 12

Colocutaneous FistulaFistula Perianal
Fig. 1. Severe perineal involvement in a young female patient with complex perianal and vaginal fistula (note the discharge of stools from the vagina). All medical therapies proved uneffective, and the patient eventually required a proctocolectomy

Fig. 2. Fibrotic stenosis of the colon in a patient with a colo-cutaneous fistula, unresponsive to all medical and endoscopic treatments. The fistula healed only with resection of the stenotic tract to define a success. Some studies rely on an improvement of symptoms, which requires the validation of fistula-specific symptom activity indexes (Table 2), which is only effective in the research setting [8].

More recently, an attempt has been made to identify more objective parameters of success, which are, in any case, prone to criticism. For example, the absence of drainage on gentle compression of the external fistula orifice for at least 1 month has been defined as complete healing, and the reduction by at least 50% of the number of external orifices is seen as a significant improvement. Clearly, the relationship of these endpoints with a real clinical improvement is doubtful, since they don't rule out the possibility of a persistent deep abscess.

Another source of variation is represented by the definition of stenosis. A stenosis caudal to the fistula (Fig. 2) may represent the reason for medical failures,

Table 2. Parameters used for the evaluation of fistula-specific activity index in Crohn's disease

Discharge

No discharge

0

Minimal mucous

1

Moderate mucous or purulent

2

Substantial

3

Gross soiling

4

Pain/restriction of activities

No restriction

0

Mild discomfort, no restriction

1

Moderate discomfort, some limitation

2

Marked discomfort, marked limitation

3

Severe pain, severe limitation

4

Restriction of sexual activity

No

0

Slight

1

Moderate

2

Marked

3

Unable to engage in sexual activity

4

Degree of induration

No

0

Minimal

1

Moderate

2

Substantial

3

Gross fluctuance/abscess

Jacobovits 84 Metro

Bernstein 80 Metro

Solomon 93 Cipro+Metro

□ Healing I Improvement

but, if considered fibrotic in nature, it also represents an exclusion criterion from most medical trials. We will review the evidence supporting the use of traditional or biological therapies in these severe, often frustrating forms of the disease.

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Responses

  • Magnus
    What is complex fistulas?
    7 years ago
  • Adalrico
    What is vagina fissure?
    7 years ago
  • belisarius
    What is the sign of fistula disease?
    2 years ago
  • everard
    What is stula disease?
    4 months ago

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