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Perianal Crohn’s Disease

  • Wing Yan Mak
  • Siew Chien Ng
Chapter

Abstract

Perianal disease affects one-third of Crohn’s disease patients. It mainly affects the young and is associated with significant morbidity and multiple surgical interventions. Perianal Crohn’s disease involves a spectrum of disorders, from fistulising to non-fistulising disease. The aetiology of perianal Crohn’s disease is not well understood. Several biomarkers including the presence of anti-Saccharomyces cerevisiae antibodies (ASCA) and OmpC antibody and persistently high CRP level have been shown to be associated with the development of perianal Crohn’s disease. The presence of proctitis is associated with poorer prognosis. Diagnosis of perianal Crohn’s disease requires careful history, physical examination, imaging with MRI or endoanal ultrasound and examination under anaesthesia.

Management of perianal Crohn’s disease is challenging. Antibiotics and immunomodulators, although can improve symptoms, do not heal perianal fistulas. About one-third of patients with perianal Crohn’s fistula respond to antitumour necrosis factor (TNF) agents, but prolonged treatment is usually necessary, and the risk of recurrence is high. Only 34% of patients remained free of relapse after 1 year of treatment. Combination of optimal medical therapy with surgical therapy (drainage of sepsis and insertion of seton) leads to a higher complete remission rate compared with single therapy. Overall, long-term infliximab therapy with combined medical and surgical management produces clinical remission in 36–58%. Importantly, deeper radiological healing on MRI has been shown to lag behind clinical remission by a median of 12 months. Therefore, multidisciplinary management including medical and surgical therapy, with radiological guidance, should be the gold standard in perianal Crohn’s disease management.

Recently, studies have shown that higher infliximab levels are associated with fistula healing. Therapeutic drug monitoring might have a role in the management of perianal Crohn’s disease. New treatment modality including mesenchymal stem cell therapy and newer generation of biological therapy including vedolizumab and ustekinumab also show promising results in perianal Crohn’s disease.

Management of perianal Crohn’s disease should have a multidisciplinary approach. Future studies focusing on identification of biomarkers associated with a complicated course of perianal Crohn’s disease are required to improve patients’ quality of life and remission rates.

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Wing Yan Mak
    • 1
    • 2
  • Siew Chien Ng
    • 3
    • 2
  1. 1.Department of Medicine and TherapeuticsFaculty of Medicine, The Chinese University of Hong KongHong KongChina
  2. 2.Prince of Wales Hospital, Hospital AuthorityHong KongChina
  3. 3.Department of Medicine and TherapeuticsCenter for Gut Microbiota Research, Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong KongHong KongChina

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