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Perianal Disease

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Crohn’s Disease

Part of the book series: Updates in Surgery ((UPDATESSURG))

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Abstract

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.

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References

  1. Rutgeerts P (2004) Review article: treatment of perianal fistulising Crohn’s disease. Aliment Pharmacol Ther 20 (Suppl 4):106–110

    Article  PubMed  Google Scholar 

  2. Nielsen OH, Rogler G, Hanholer D, Thomsen OØ (2009) Diagnosis and management of fistulising Crohn’s disease. Nat Clin Pract Gastroenterol Hepatol, In press

    Google Scholar 

  3. Hellers G, Bergstrand O, Ewerth S, Holstrom B (1980) Occurrence and outcome after primary treatment of anal fistulae in Crohn’s disease. Gut 21:525–527

    Article  PubMed  CAS  Google Scholar 

  4. Schwartz D, Loftus EV Jr, Tremaine W et al (2002) The natural history of fistulising Crohn’s disease in Olmsted County, Minnesota. Gastroenterology 122:525–527

    Article  Google Scholar 

  5. Judge TA, Lichtenstein GR (2004) Treatment of fistulising Crohn’s disease. Gastroenterol Clin North Am 33:421–454

    Article  PubMed  Google Scholar 

  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 50:1260–1263

    Article  PubMed  CAS  Google Scholar 

  7. Nordgren S, Fasth S, Hulten L (1992) Anal fistulas in Crohn’s disease: incidence and outcome of surgical treatment. Int J Colorectal Dis 7:214–218

    Article  PubMed  CAS  Google Scholar 

  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 38:389–392

    Article  PubMed  CAS  Google Scholar 

  9. Loly C, Belaiche J, Louis E (2008) Predictors of severe Crohn’s disease. Scand J Gastroenterol 4:1–8

    Google Scholar 

  10. Sachar DB, Bodian CA, Goldstein ES et al (2005) Is perianal Crohn’s disease associated with intestinal fistulisation? Am J Gastroenterol 100:1547–1549

    Article  PubMed  Google Scholar 

  11. Beaugerie L, Seksik P, Nion-Larmurier I et al (2006) Predictors of Crohn’s disease. J Gastroenterology 130:650–656

    Article  Google Scholar 

  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 14:1436–1439

    Article  Google Scholar 

  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 25:1–20

    Google Scholar 

  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 16:292–297

    Article  PubMed  CAS  Google Scholar 

  15. Kleinubing H Jr, Jannini JF, Malafaia O et al (2000) Transperineal ultrasonography: a new method to image the anorectal region. Dis Colon Rectum 43:1572–1574

    Article  PubMed  Google Scholar 

  16. Weisman RI, Orsay CP, Pearl RK, Abcarian H (1991) The role of fistulography in fistula-inano. Dis Colon Rectum 34:181–184

    Article  PubMed  CAS  Google Scholar 

  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 25:582–586

    Article  PubMed  CAS  Google Scholar 

  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 98:332–339

    Article  PubMed  Google Scholar 

  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 121:1064–1072

    Article  PubMed  CAS  Google Scholar 

  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 233:674–681

    Article  PubMed  Google Scholar 

  21. Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63:1–2

    Article  PubMed  CAS  Google Scholar 

  22. Schwartz DA, Pemberton JH, Sandborn WJ (2001) Diagnosis and treatment of perianal fistulas in Crohn’s disease. Ann Intern Med 135:906–918

    PubMed  CAS  Google Scholar 

  23. Hughes LE (1992) Clinical classification of perianal Crohn’s disease. Dis Colon Rectum 35:928–932

    Article  PubMed  CAS  Google Scholar 

  24. Irvine EJ (1995) Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. J Clin Gastroenterol 20:27–32

    Article  PubMed  CAS  Google Scholar 

  25. Satsangi J, Silverberg MS, Vermeire S, Colombel JF (2006) The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut 55:749–753

    Article  PubMed  CAS  Google Scholar 

  26. Bell SJ, Williams AB, Wiesel P et al (2003) The clinical course of fistulising Crohn’s disease. Aliment Pharmacol Ther 17:1145–1151

    Article  PubMed  CAS  Google Scholar 

  27. Carter MJ, Lobo AJ, Travis SPL (2004) Guidelines for the management of inflammatory bowel disease in adults. Gut 53 (Suppl V):v1–v16

    Article  PubMed  Google Scholar 

  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–i58

    Article  PubMed  Google Scholar 

  29. Brandt LJ, Berstein LH, Baley SJ et al (1982) Metronidazole therapy for perineal Crohn’s disease: a follow-up study. Gastroenterology 83:383–387

    PubMed  CAS  Google Scholar 

  30. Jacobovits J, Schuster MM (1984) Metronidazole therapy for Crohn’s disease and associated fistulae. Am J Gastroenterol 79:533–540

    Google Scholar 

  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 7:571–573

    Google Scholar 

  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 18:1113–1120

    Article  PubMed  CAS  Google Scholar 

  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 15:17–24

    Article  PubMed  Google Scholar 

  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 20:1329–1336

    Article  CAS  Google Scholar 

  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 88:1198–1205

    PubMed  CAS  Google Scholar 

  36. Pearson DC, May GR, Fick GH et al (1995) Azathioprine and 6-mercaptopurine in Crohn’s disease. A meta-analysis. Ann Intern Med 122:132–142

    Google Scholar 

  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 340:1398–1405

    Article  PubMed  CAS  Google Scholar 

  38. Sands BE, Anderson FH, Bernstein CN et al (2004) Infliximab maintenance therapy for fistulizing Crohn’s disease. N Eng J Med 350:876–885

    Article  CAS  Google Scholar 

  39. Ochsenkuhn T, Goke B, Sackmann M (2002) Combining infliximab with mercaptopurine/azathioprine for fistula therapy in Crohn’s disease. Am J Gastroenterol 97:2022–2025

    PubMed  Google Scholar 

  40. Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB (2003) AGA technical review on perianal Crohn’s disease. Gastroenterology 125:1508–1530

    Article  PubMed  Google Scholar 

  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 130:323–333

    Article  PubMed  CAS  Google Scholar 

  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 146:829–838

    PubMed  Google Scholar 

  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 132:1641–1657

    Article  Google Scholar 

  44. Sandborn WJ, Feagan BG, Stoinov S et al (2007) Certolizumab pegol for the treatment of Crohn’s disease. N Eng J Med 357:228–238

    Article  CAS  Google Scholar 

  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 357:239–250

    Article  CAS  Google Scholar 

  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 125:380–388

    Article  PubMed  CAS  Google Scholar 

  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 103:1721–1729

    PubMed  Google Scholar 

  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 48:970–974

    Article  PubMed  Google Scholar 

  49. Hart AL, Plamondon S, Kamm MA (2007) Topical tacrolimus in the treatment of perianal Crohn’s disease. Inflamm Bowel Dis 13:245–253

    Article  PubMed  Google Scholar 

  50. Williams JG, Farrands PA, Williams AB et al (2007) The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 9 (Suppl 4):18–50

    Article  PubMed  Google Scholar 

  51. Makowiec F, Jehle EC, Starlinger M (1995) Clinical course of perianal fistulas in Crohn’s disease. Gut 37:696–701

    Article  PubMed  CAS  Google Scholar 

  52. Scott HJ, Northover JMA (1996) Evaluation of surgery for perianal Crohn’s disease. Dis Colon Rectum 39:1039–1043

    Article  PubMed  CAS  Google Scholar 

  53. Halme L, Sainio AP (1995) Factors related to frequency, type, and outcome of anal fistulas in Crohn’s disease. Dis Colon Rectum 38:55–59

    Article  PubMed  CAS  Google Scholar 

  54. Saclarides TI (2002) Rectovaginal fistula. Surg Clin North Am 1261–1272

    Google Scholar 

  55. Williams JG, MacLeod CA, Rothenberger DA, Goldberg SM (1991) Seton treatment of high anal fistulae. Br J Surg 78:1159–1161

    Article  PubMed  CAS  Google Scholar 

  56. Larson DW, Pemberton JH (2004) Current concepts and controversies in surgery for IBD. Gastroenterology 126:1611–1619

    Article  PubMed  Google Scholar 

  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 22:1107–1113

    Article  PubMed  CAS  Google Scholar 

  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 9:98–103

    Article  PubMed  Google Scholar 

  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 46:577–583

    Article  PubMed  Google Scholar 

  60. Talbot C, Sagar PM, Johnston MJ et al (2005) Infliximab in the surgical management of complex fistulating anal Crohn’s disease. Colorectal Dis 7:164–168

    Article  PubMed  CAS  Google Scholar 

  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 49:1837–1841

    Article  PubMed  Google Scholar 

  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 2:11–15

    Article  Google Scholar 

  63. Frizelle fA, Santoro GA, Pamberton JH (1996) The management of perianal Crohn’s disease. Int J Colorectal Dis 11:227–237

    Article  PubMed  CAS  Google Scholar 

  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 68:528–530

    Article  PubMed  CAS  Google Scholar 

  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 20:343–347

    Article  PubMed  CAS  Google Scholar 

  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 48:936–939

    Article  Google Scholar 

  67. Mueller MH, Geis M, Glatzle J et al (2007) Risk of faecal diversion in complicated perianal Crohn’s disease. J Gastrointest Surg 11:529–537

    Article  PubMed  CAS  Google Scholar 

  68. Joo JS, Weiss EG, Nogueras JJ, Wexner SD (1998) Endorectal advancement flap in perianal Crohn’s disease. Am Surg 64:157–160

    Google Scholar 

  69. Kodner IJ, Mazor A, Shemesh EI et al (1993) Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas. Surgery 114:682–690

    PubMed  CAS  Google Scholar 

  70. O’Leary DP, Durdey P, Milroy CE (1998) Definitive repair of anovaginal fistula in Crohn’s disease. Ann Royal Coll Surg Engl 64:147–150

    Google Scholar 

  71. Zmora O, Mizrhai N, Rotholtz N et al (2003) Fibrin glue sealing in the treatment of perineal fistulas. Dis Colon Rectum 46:584–589

    Article  PubMed  Google Scholar 

  72. Loungnarath R, Dietz DW, Mutch MG et al (2004) Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum 47:432–436

    Article  PubMed  Google Scholar 

  73. Committee Consensus Statement (2008) The Surgisis® AFPTM anal fistula plug: report of a consensus conference. Colorectal Dis 10:17–20

    Google Scholar 

  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 23:319–324

    Article  PubMed  CAS  Google Scholar 

  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 49:1569–1573

    Article  PubMed  Google Scholar 

  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 248:39–43

    Article  PubMed  Google Scholar 

  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 15:463–473

    Article  CAS  Google Scholar 

  78. Lichtiger S (2001) Healing of perianal fistulae by local injection of antibody to TNF. Gastroenterology 120(Suppl):A3154

    Google Scholar 

  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 48:768–774

    Article  PubMed  CAS  Google Scholar 

  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 41:1064–1072

    Article  PubMed  CAS  Google Scholar 

  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 52:79–86

    PubMed  Google Scholar 

  82. Irvine EJ (1995) Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. J Clin Gastroenterol 20:27–32

    Article  PubMed  CAS  Google Scholar 

  83. Gaertner WB, Hagerman GF, Finne CO et al (2008) Fistula-associated anal adenocarcinoma: good results with aggressive therapy. Dis Colon Rectum 51:1061–1067

    Article  PubMed  Google Scholar 

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Alessandroni, L. (2010). Perianal Disease. In: Tersigni, R., Prantera, C. (eds) Crohn’s Disease. Updates in Surgery. Springer, Milano. https://doi.org/10.1007/978-88-470-1472-5_16

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