Perianal Disease

  • Luciano Alessandroni
Part of the Updates in Surgery book series (UPDATESSURG)


Perianal Crohn’s disease (PACD) refers to the involvement of the perianal and perineal region in the inflammatory process of the disease. Perianal disease is a frequent complication of Crohn’s disease (CD), can result in morbidity and low quality of life, and its management is difficult and controversial [1]. Despite recent advances in the diagnosis and treatment of PACD, the primary goals of management remain unchanged: relief of symptoms, control of sepsis, and avoidance of permanent stoma. The complete healing of perianal lesions remains a goal for the future.


External Anal Sphincter Anal Fistula Rectovaginal Fistula Certolizumab Pegol Perianal Fistula 


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  1. 1.
    Rutgeerts P (2004) Review article: treatment of perianal fistulising Crohn’s disease. Aliment Pharmacol Ther 20 (Suppl 4):106–110CrossRefPubMedGoogle Scholar
  2. 2.
    Nielsen OH, Rogler G, Hanholer D, Thomsen OØ (2009) Diagnosis and management of fistulising Crohn’s disease. Nat Clin Pract Gastroenterol Hepatol, In pressGoogle Scholar
  3. 3.
    Hellers G, Bergstrand O, Ewerth S, Holstrom B (1980) Occurrence and outcome after primary treatment of anal fistulae in Crohn’s disease. Gut 21:525–527CrossRefPubMedGoogle Scholar
  4. 4.
    Schwartz D, Loftus EV Jr, Tremaine W et al (2002) The natural history of fistulising Crohn’s disease in Olmsted County, Minnesota. Gastroenterology 122:525–527CrossRefGoogle Scholar
  5. 5.
    Judge TA, Lichtenstein GR (2004) Treatment of fistulising Crohn’s disease. Gastroenterol Clin North Am 33:421–454CrossRefPubMedGoogle Scholar
  6. 6.
    West RL, Van der Woude CJ, Endtz HP et al (2005) Perianal fistulas in Crohn’s disease are predominantly colonized by skin flora: implications for antibiotic treatment? Dig Dis Sci 50:1260–1263CrossRefPubMedGoogle Scholar
  7. 7.
    Nordgren S, Fasth S, Hulten L (1992) Anal fistulas in Crohn’s disease: incidence and outcome of surgical treatment. Int J Colorectal Dis 7:214–218CrossRefPubMedGoogle Scholar
  8. 8.
    Williamson PR, Hellinger MD, Larach SW, Ferrara A (1995) Twenty-year review of the surgical management of perianal Crohn’s disease. Dis Colon Rectum 38:389–392CrossRefPubMedGoogle Scholar
  9. 9.
    Loly C, Belaiche J, Louis E (2008) Predictors of severe Crohn’s disease. Scand J Gastroenterol 4:1–8Google Scholar
  10. 10.
    Sachar DB, Bodian CA, Goldstein ES et al (2005) Is perianal Crohn’s disease associated with intestinal fistulisation? Am J Gastroenterol 100:1547–1549CrossRefPubMedGoogle Scholar
  11. 11.
    Beaugerie L, Seksik P, Nion-Larmurier I et al (2006) Predictors of Crohn’s disease. J Gastroenterology 130:650–656CrossRefGoogle Scholar
  12. 12.
    Bonheur JL, Braunstein J, Korelitz BI et al (2008) Anal skin tags in inflammatory bowel disease: new observations and a clinical review. Inflamm Bowel Dis 14:1436–1439CrossRefGoogle Scholar
  13. 13.
    Orsoni P, Barthet M, Portier F et al (1999) Prospective comparison of endosonography, magnetic resonance imaging and surgical findings in anorectal fistula and abscess complicating Crohn’s disease. Br J Surg 25:1–20Google Scholar
  14. 14.
    Sloots C, Felt-Bersma RJ, Poen AC et al (2001) Assessment and classification of fistula-inano in patients with Crohn’s disease by hydrogen peroxide enhanced transanal ultrasound. Int J Colorectal Dis 16:292–297CrossRefPubMedGoogle Scholar
  15. 15.
    Kleinubing H Jr, Jannini JF, Malafaia O et al (2000) Transperineal ultrasonography: a new method to image the anorectal region. Dis Colon Rectum 43:1572–1574CrossRefPubMedGoogle Scholar
  16. 16.
    Weisman RI, Orsay CP, Pearl RK, Abcarian H (1991) The role of fistulography in fistula-inano. Dis Colon Rectum 34:181–184CrossRefPubMedGoogle Scholar
  17. 17.
    Schratter-Sehn AU, Lochs H, Vogelsang H et al (1993) Endoscopic ultrasonography versus computed tomography in the differential diagnosis of perianorectal complications of Crohn’s disease. Endoscopy 25:582–586CrossRefPubMedGoogle Scholar
  18. 18.
    Van Assche G, Vanbeckevoort D, Bielen D et al (2003) Magnetic resonance imaging of the effects of infliximab on perianal fistulising Crohn’s disease. Am J Gastroenterol 98:332–339CrossRefPubMedGoogle Scholar
  19. 19.
    Schwartz DA, Wiersema MJ, Dudiak KM et al (2001) A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anaesthesia for evaluation of Crohn’s perianal fistulas. Gastroenterology 121:1064–1072CrossRefPubMedGoogle Scholar
  20. 20.
    Buchanan GN, Halligan S, Bartram CI et al (2004) Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology 233:674–681CrossRefPubMedGoogle Scholar
  21. 21.
    Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63:1–2CrossRefPubMedGoogle Scholar
  22. 22.
    Schwartz DA, Pemberton JH, Sandborn WJ (2001) Diagnosis and treatment of perianal fistulas in Crohn’s disease. Ann Intern Med 135:906–918PubMedGoogle Scholar
  23. 23.
    Hughes LE (1992) Clinical classification of perianal Crohn’s disease. Dis Colon Rectum 35:928–932CrossRefPubMedGoogle Scholar
  24. 24.
    Irvine EJ (1995) Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. J Clin Gastroenterol 20:27–32CrossRefPubMedGoogle Scholar
  25. 25.
    Satsangi J, Silverberg MS, Vermeire S, Colombel JF (2006) The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut 55:749–753CrossRefPubMedGoogle Scholar
  26. 26.
    Bell SJ, Williams AB, Wiesel P et al (2003) The clinical course of fistulising Crohn’s disease. Aliment Pharmacol Ther 17:1145–1151CrossRefPubMedGoogle Scholar
  27. 27.
    Carter MJ, Lobo AJ, Travis SPL (2004) Guidelines for the management of inflammatory bowel disease in adults. Gut 53 (Suppl V):v1–v16CrossRefPubMedGoogle Scholar
  28. 28.
    Caprilli R, Gassull MA, Escher JC et al (2006) European evidence based consensus on the diagnosis and management of Crohn’s disease: special situations. Gut 55:i36–i58CrossRefPubMedGoogle Scholar
  29. 29.
    Brandt LJ, Berstein LH, Baley SJ et al (1982) Metronidazole therapy for perineal Crohn’s disease: a follow-up study. Gastroenterology 83:383–387PubMedGoogle Scholar
  30. 30.
    Jacobovits J, Schuster MM (1984) Metronidazole therapy for Crohn’s disease and associated fistulae. Am J Gastroenterol 79:533–540Google Scholar
  31. 31.
    Solomon MJ, McLeod RS, O’Connor BJ et al (1993) Combination ciprofloxacin and metron-idazole in severe perianal Crohn’s disease. Can J Gastroenterol 7:571–573Google Scholar
  32. 32.
    Dejaco C, Harrer M, Waldhoer T et al (2003) Antibiotics and azathioprine for the treatment of perianal fistulas in Crohn’s disease. Aliment Pharmacol Ther 18:1113–1120CrossRefPubMedGoogle Scholar
  33. 33.
    Thia KT, Mahadevan U, Feagan BG et al (2009) Ciprofloxacin of metronidazole for the treatment of perianal fistulas in patients with Crohn’s disease: a randomized, double blind, placebo-controlled pilot study. Inflamm Bowel Dis 15:17–24CrossRefPubMedGoogle Scholar
  34. 34.
    West RL, Van der Woude CJ, Hansen BE et al (2004) Clinical and endosonographic effect of ciprofloxacin treatment of perianal fistulae in Crohn’s disease with infliximab: a doubleblind placebo-controlled study. Alimen Pharmacol Ther 20:1329–1336CrossRefGoogle Scholar
  35. 35.
    Korelitz BI, Adler DJ, Mendhelsohn RA et al (1993) Long-term experience with 6-mercaptopurine in the treatment of Crohn’s disease. Am J Gastroenterol 88:1198–1205PubMedGoogle Scholar
  36. 36.
    Pearson DC, May GR, Fick GH et al (1995) Azathioprine and 6-mercaptopurine in Crohn’s disease. A meta-analysis. Ann Intern Med 122:132–142Google Scholar
  37. 37.
    Present DH, Rutgeerts P, Targan S et al (1999) Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 340:1398–1405CrossRefPubMedGoogle Scholar
  38. 38.
    Sands BE, Anderson FH, Bernstein CN et al (2004) Infliximab maintenance therapy for fistulizing Crohn’s disease. N Eng J Med 350:876–885CrossRefGoogle Scholar
  39. 39.
    Ochsenkuhn T, Goke B, Sackmann M (2002) Combining infliximab with mercaptopurine/azathioprine for fistula therapy in Crohn’s disease. Am J Gastroenterol 97:2022–2025PubMedGoogle Scholar
  40. 40.
    Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB (2003) AGA technical review on perianal Crohn’s disease. Gastroenterology 125:1508–1530CrossRefPubMedGoogle Scholar
  41. 41.
    Hanauer SB, Sandborn WJ, Rutgeerts P et al (2006) Human anti-tumor necrosis factor monoclonal antibody (adalimumab) in Crohn’s disease: the CLASSIC-I trial. Gastroenterology 130:323–333CrossRefPubMedGoogle Scholar
  42. 42.
    Sandborn WJ, Rutgeerts P, Enns R et al (2007) Adalimumab induction therapy for Crohn’s disease previously treated with infliximab: a randomized trial. Ann Intern Med 146:829–838PubMedGoogle Scholar
  43. 43.
    Colombel JF, Sandborn WJ, Rutgeerts P et al (2007) Adalimumab for maintenance of clinical response and remission in patients with Crohn’s disease: the CHARM trial. Gastroenterology 132:1641–1657CrossRefGoogle Scholar
  44. 44.
    Sandborn WJ, Feagan BG, Stoinov S et al (2007) Certolizumab pegol for the treatment of Crohn’s disease. N Eng J Med 357:228–238CrossRefGoogle Scholar
  45. 45.
    Schreiber S, Khaliq-Kareemi M, Lawrence IC et al (2007) Maintenance therapy with certolizumab pegol for the treatment of Crohn’s disease. N Eng J Med 357:239–250CrossRefGoogle Scholar
  46. 46.
    Sandborn WJ, Present DH, Isaacs KL et al (2003) Tacrolimus for the treatment of fistulas in patients with Crohn’s disease: a randomized, placebo-controlled trial. Gastroenterology 125:380–388CrossRefPubMedGoogle Scholar
  47. 47.
    Fukuda Y, Takazoe M, Sugita A et al (2008) Oral spheric adsorptive carbon for the treatment of intractable anal fistulas in Crohn’s disease: a multicenter, randomized, double-blind, placebo-controlled trial. Am J Gastroenterol 103:1721–1729PubMedGoogle Scholar
  48. 48.
    Stringer EE, Nicholson TJ, Armstrong D (2005) Efficacy of topical metronidazole (10 percent) in the treatment of anorectal Crohn’s disease. Dis Colon Rectum 48:970–974CrossRefPubMedGoogle Scholar
  49. 49.
    Hart AL, Plamondon S, Kamm MA (2007) Topical tacrolimus in the treatment of perianal Crohn’s disease. Inflamm Bowel Dis 13:245–253CrossRefPubMedGoogle Scholar
  50. 50.
    Williams JG, Farrands PA, Williams AB et al (2007) The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 9 (Suppl 4):18–50CrossRefPubMedGoogle Scholar
  51. 51.
    Makowiec F, Jehle EC, Starlinger M (1995) Clinical course of perianal fistulas in Crohn’s disease. Gut 37:696–701CrossRefPubMedGoogle Scholar
  52. 52.
    Scott HJ, Northover JMA (1996) Evaluation of surgery for perianal Crohn’s disease. Dis Colon Rectum 39:1039–1043CrossRefPubMedGoogle Scholar
  53. 53.
    Halme L, Sainio AP (1995) Factors related to frequency, type, and outcome of anal fistulas in Crohn’s disease. Dis Colon Rectum 38:55–59CrossRefPubMedGoogle Scholar
  54. 54.
    Saclarides TI (2002) Rectovaginal fistula. Surg Clin North Am 1261–1272Google Scholar
  55. 55.
    Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM (1991) Seton treatment of high anal fistulae. Br J Surg 78:1159–1161CrossRefPubMedGoogle Scholar
  56. 56.
    Larson DW, Pemberton JH (2004) Current concepts and controversies in surgery for IBD. Gastroenterology 126:1611–1619CrossRefPubMedGoogle Scholar
  57. 57.
    Domenech E, Hinojosa J, Nos P et al (2005) Clinical evolution of luminal and perianal Crohn’s disease after inducing remission with Infliximab: how long should patients be treated? Aliment Pharmacol Ther 22:1107–1113CrossRefPubMedGoogle Scholar
  58. 58.
    Regueiro M, Mardini H (2003) Treatment of perianal fistulizing Crohn’s disease with infliximab alone or as an adjunct to exam under anaesthesia with seton placement. Inflamm Bowel Dis 9:98–103CrossRefPubMedGoogle Scholar
  59. 59.
    Topstad DR, Panaccione R, Heine JA et al (2003) Combined seton placement, infliximab infusion, and maintenance immunosuppressives improve healing rate in fistulising anorectal Crohn’s disease: a single center experience. Dis Colon Rectum 46:577–583CrossRefPubMedGoogle Scholar
  60. 60.
    Talbot C, Sagar PM, Johnston MJ et al (2005) Infliximab in the surgical management of complex fistulating anal Crohn’s disease. Colorectal Dis 7:164–168CrossRefPubMedGoogle Scholar
  61. 61.
    Hyder SA, Travis SP, Jewell DP et al (2006) Fistulating anal Crohn’s disease: results of combined surgical and Infliximab treatment. Dis Colon Rectum 49:1837–1841CrossRefPubMedGoogle Scholar
  62. 62.
    Burman JM, Thompson M, Cooke WT, Alexander-Williams J (1971) The effects of diversion of intestinal contents on the progress of Crohn’s disease of the large bowel. Gut 2:11–15CrossRefGoogle Scholar
  63. 63.
    Frizelle fA, Santoro GA, Pamberton JH (1996) The management of perianal Crohn’s disease. Int J Colorectal Dis 11:227–237CrossRefPubMedGoogle Scholar
  64. 64.
    Heuman R, Bolin T, Sjodhal R et al (1981) The incidence and course of perianal complications and arthralgia after intestinal resection with restoration of continuity for Crohn’s disease. Br J Surg 68:528–530CrossRefPubMedGoogle Scholar
  65. 65.
    Orkin BA, Telander RL (1985) Effect of intra-abdominal resection or fecal diversion of perianal Crohn’s disease in pediatric Crohn’s disease. J Pediatr Surg 20:343–347CrossRefPubMedGoogle Scholar
  66. 66.
    Fichera A, McCormack R, Rubin MA et al (2005) Long-term outcome of surgically treated Crohn’s colitis: a prospective study. Dis Colon Rectum 48:936–939CrossRefGoogle Scholar
  67. 67.
    Mueller MH, Geis M, Glatzle J et al (2007) Risk of faecal diversion in complicated perianal Crohn’s disease. J Gastrointest Surg 11:529–537CrossRefPubMedGoogle Scholar
  68. 68.
    Joo JS, Weiss EG, Nogueras JJ, Wexner SD (1998) Endorectal advancement flap in perianal Crohn’s disease. Am Surg 64:157–160Google Scholar
  69. 69.
    Kodner IJ, Mazor A, Shemesh EI et al (1993) Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 114:682–690PubMedGoogle Scholar
  70. 70.
    O’Leary DP, Durdey P, Milroy CE (1998) Definitive repair of anovaginal fistula in Crohn’s disease. Ann Royal Coll Surg Engl 64:147–150Google Scholar
  71. 71.
    Zmora O, Mizrhai N, Rotholtz N et al (2003) Fibrin glue sealing in the treatment of perineal fistulas. Dis Colon Rectum 46:584–589CrossRefPubMedGoogle Scholar
  72. 72.
    Loungnarath R, Dietz DW, Mutch MG et al (2004) Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum 47:432–436CrossRefPubMedGoogle Scholar
  73. 73.
    Committee Consensus Statement (2008) The Surgisis® AFPTM anal fistula plug: report of a consensus conference. Colorectal Dis 10:17–20Google Scholar
  74. 74.
    Schwandner O, Stadler F, Dietl O et al (2008) Initial experience on efficacy in closure of cryptoglandular and Crohn’s transphinteric fistulas by the use of the anal fistula plug. Int J Colorectal Dis 23:319–324CrossRefPubMedGoogle Scholar
  75. 75.
    O’Connor L, Champagne BJ, Ferguson MA et al (2006) Efficacy of anal fistula plug in closure of Crohn’s anorectal fistulas. Dis Colon Rectum 49:1569–1573CrossRefPubMedGoogle Scholar
  76. 76.
    Wexner D, Ruiz DE, Genua J et al (2008) Gracilis muscle interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas: results in 53 patients. Ann Surg 248:39–43CrossRefPubMedGoogle Scholar
  77. 77.
    Cornillie F, Dhealy D, D’Haems G et al (2001) Infliximab induces potent anti-inflammatory and local activity, but no systemic immune suppression in patients with Crohn’s disease. Alimen Pharmacol Ther 15:463–473CrossRefGoogle Scholar
  78. 78.
    Lichtiger S (2001) Healing of perianal fistulae by local injection of antibody to TNF. Gastroenterology 120(Suppl):A3154Google Scholar
  79. 79.
    Poggioli G, Laureti S, Pierangeli F et al (2005) Local injection of infliximab for the treatment of perianal Crohn’s disease. Dis Colon Rectum 48:768–774CrossRefPubMedGoogle Scholar
  80. 80.
    Asteria CR, Ficari F, Bagnoli et al (2006) Treatment of perianal fistulas in Crohn’s disease by local injection of antibody to TNF-alpha accounts for a favourable response in selected cases: a pilot study. Scand J Gastroenterol 41:1064–1072CrossRefPubMedGoogle Scholar
  81. 81.
    Garcia-Olmo D, Herreros D, Pascual I et al (2009) Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial. Dis Colon Rectum 52:79–86PubMedGoogle Scholar
  82. 82.
    Irvine EJ (1995) Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. J Clin Gastroenterol 20:27–32CrossRefPubMedGoogle Scholar
  83. 83.
    Gaertner WB, Hagerman GF, Finne CO et al (2008) Fistula-associated anal adenocarcinoma: good results with aggressive therapy. Dis Colon Rectum 51:1061–1067CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia 2010

Authors and Affiliations

  • Luciano Alessandroni
    • 1
  1. 1.Department of SurgerySan Camillo-Forlanini HospitalRomeItaly

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