Perianal Abscesses and Fistulae

Perianal abscesses and fistulae were the most frequent complications of IBD of patients who required emergency treatment in our series. Many of them underwent more than one operation for fistulae. When cases of Crohn's disease are described as "fis-tulising", one has to distinguish between perianal and intestinal fistulation. The question, however, remains open as to whether or not there is truly an association between perianal fistulisation and intraabdominal intestinal fistulisation in CD. There is a statistically significant association between perianal CD and intestinal fistulisation, which is much stronger and more consistent in cases of Crohn's colitis than in cases limited to the small bowel [3]. The management of perianal CD continues to be challenging. Roughly half of patients require permanent faecal diversion, which is even more frequently true for patients with colonic CD and anal stenosis. Recognising these tendencies will assist both patients and surgeons in planning optimal treatment [4]. If it is indeed a superficial fistula, the correct course of action for most patients would be a fistulotomy and perhaps a short course of antibiotics. Failing this, most patients would receive a non-cutting seton [5]. Long-term indwelling seton is an effective management modality for complex perianal Crohn's fistulas which do not negatively impact faecal continence [6].

Endoanal ultrasound has been suggested for the evaluation of rectal abscesses and fistulas [7]. The insertion of rectal probes can, however, still be painful. The use of a rigid endoanal ultrasound probe can even be impossible in patients with inflammatory perianal disease due to anal stenosis. This limitation is obviated by the use of perineal ultrasonography, which is a simple, painless, feasible, real-time method that can be performed without specific patient preparation and which is comparable in its sensitivity to pelvic MRI in the detection of perianal fistulae and/or abscesses [8]. The combination of MRI and endoanal ultrasound is capable of detecting perianal fistulae with a sensitivity of 100% [9]. We have little experience with perineal ultrasonography. In our opinion, transrectal ultrasonography is an excellent method in cases of newly diagnosed perianal disease, but it is less exact in cases of recurrent fistulae.

Rectovaginal fistulae are a well-recognized complication of Crohn's disease, occurring in 5-10% of women [10]. The management of rectovaginal fistu-lae complicating Crohn's disease is often unsatisfactory. Faecal diversion has been used to achieve remission in colonic Crohn's disease [11]. Most patients with rectovaginal fistulae secondary to rectal disease, even if it is quiescent, eventually require a proctectomy due to progressive rectal disease or unmanageable incontinence [12,13]. The role of faecal diversion applied on its own in perianal Crohn's disease remains unclear. Many perianal lesions, particularly ulcers and fistulae, heal completely without any specific therapy [14]. The advantage of fecal diversion is that it is a relatively minor procedure, and it may promote healing of an anal ulcer and some fistulae. It would be helpful if we could predict which patients with perianal disease might respond to faecal diversion. No predictive factors could be found by Yamamoto et al. [15]. Patients have to be warned that the ileostomy is closed in only a few cases, but that the severe sepsis or anal pain is usually alleviated. Our two patients who underwent ileostomy for intractable perianal CD didn't ask for a closure of ileostomy until now.

Infliximab is an efficacious treatment for fistulae in patients with Crohn's disease [16]. The perianal disease process should first be fully delineated with endoscopy and either MRI or EUS before treatment is begun. Although the initial response to infliximab is dramatic, the median duration of fistula closure is approximately 3 months, and repeated infusions are required [16]. Patients with fistulising CD treated with infliximab are more likely to maintain fistula closure if the treatment is preceded by an evaluation under anaesthesia and seton placement [17]. Complex fistulae first require surgical intervention prior to medical treatment. A combination of antibiotics, immunosuppressive therapy and infliximab are then initiated to facilitate fistula healing [18]. Two of our patients have been treated with infliximab; both of them, finally, required an ileostomy for permanent improvement of their perianal disease.

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