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Penetrating Crohn’s Disease and Fistulae

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Inflammatory Bowel Disease Nursing Manual

Abstract

Crohn’s disease can affect the bowel anywhere in the gastrointestinal tract, but most commonly affects the small bowel and perianal areas, where it may cause fistulae to form. Both enteric fistulae arising from the small bowel and perianal fistulae affecting the anorectum cause significant suffering for patients and are clinically difficult to treat. This chapter covers the manifestations and management options for fistulating Crohn’s disease.

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References

  • Bellolio F, Cohen Z, Macrae HM, O'connor BI, Huang H, Victor JC, Mcleod RS (2013) Outcomes following surgery for perforating Crohn’s disease. Br J Surg 100:1344–1348

    Article  CAS  Google Scholar 

  • Bor R, Farkas K, Balint A, Szucs M, Abraham S, Baradnay G, Wittmann T, Szepes Z, Nagy F, Molnar T (2015) Efficacy of combined anti-TNF-alpha and surgical therapy in perianal and enterocutaneous fistulizing Crohn's disease—clinical observations from a tertiary eastern European center. Scand J Gastroenterol 50:182–187

    Article  CAS  Google Scholar 

  • Bor R, Farkas K, Fabian A, Balint A, Milassin A, Rutka M, Matuz M, Nagy F, Szepes Z, Molnar T (2017) Clinical role, optimal timing and frequency of serum infliximab and anti-infliximab antibody level measurements in patients with inflammatory bowel disease. PLoS One 12:e0172916

    Article  Google Scholar 

  • Borley NR, Mortensen NJ, Jewell DP (1999) MRI scanning in perianal Crohn's disease: an important diagnostic adjunct. Inflamm Bowel Dis 5:231–233 discussion 234

    Article  CAS  Google Scholar 

  • Brochard C, Siproudhis L, Leveque J, Grouin A, Mallet AL, Bretagne JF, Ropert A, Bouguen G (2017) Factors associated with fecal incontinence in women of childbearing age with Crohn’s disease. Inflamm Bowel Dis 23:775–780

    Article  Google Scholar 

  • Coelho R, Magro F, Silva M, Macedo G (2016) Early surgery in Crohn's disease patients with entero-urinary fistulas: does it change the prognosis? Scand J Gastroenterol 51:679–683

    Article  Google Scholar 

  • Colombel JF, Sandborn WJ, Rutgeerts P, Enns R, Hanauer SB, Panaccione R, Schreiber S, Byczkowski D, Li J, Kent JD, Pollack PF (2007) Adalimumab for maintenance of clinical response and remission in patients with Crohn's disease: the CHARM trial. Gastroenterology 132:52–65

    Article  CAS  Google Scholar 

  • de Groof EJ, Sahami S, Lucas C, Ponsioen CY, Bemelman WA, Buskens CJ (2016) Treatment of perianal fistula in Crohn's disease: a systematic review and meta-analysis comparing seton drainage and anti-tumour necrosis factor treatment. Color Dis 18:667–675

    Article  Google Scholar 

  • El-Gazzaz G, Hull T, Church JM (2012) Biological immunomodulators improve the healing rate in surgically treated perianal Crohn's fistulas. Color Dis 14:1217–1223

    Article  CAS  Google Scholar 

  • Farrer K, Lal S, Teubner A, Harper L, Abraham A, Myers A, Carlson GL (2015) Fistuloclysis and distal enteral feeding in acute intestinal failure. Clin Nutr ESPEN 10:e189

    Article  CAS  Google Scholar 

  • Gecse K, Khanna R, Stoker J, Jenkins JT, Gabe S, Hahnloser D, D'Haens G (2013) Fistulizing Crohn's disease: diagnosis and management. United European Gastroenterol J 1:206–213

    Article  Google Scholar 

  • Gecse KB, Bemelman W, Kamm MA, Stoker J, Khanna R, Ng SC, Panes J, van Assche G, Liu Z, Hart A, Levesque BG, D'Haens G, World Gastroenterology Organization, International Organisation for Inflammatory Bowel Diseases IOIBD, European Society of Coloproctology and Robarts Clinical Trials (2014) A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease. Gut 63:1381–1392

    Article  Google Scholar 

  • Geltzeiler CB, Hart KD, Lu KC, Deveney KE, Herzig DO, Tsikitis VL (2015) Trends in the surgical Management of Crohn's disease. J Gastrointest Surg 19:1862–1868

    Article  Google Scholar 

  • Gligorijevic V, Spasic N, Bojic D, Protic M, Svorcan P, Maksimovic B, Markovic V, Krivokapic Z, Jojic N (2010) The role of pelvic MRI in assesment of combined surgical and infliximab treatment for perianal Crohn's disease. Acta Chir Iugosl 57:89–95

    Article  CAS  Google Scholar 

  • Goel RM, Blaker P, Mentzer A, Fong SC, Marinaki AM, Sanderson JD (2015) Optimizing the use of thiopurines in inflammatory bowel disease. Ther Adv Chronic Dis 6:138–146

    Article  CAS  Google Scholar 

  • Gottgens KW, Jeuring SF, Sturkenboom R, Romberg-Camps MJ, Oostenbrug LE, Jonkers DM, Stassen LP, Masclee AA, Pierik MJ, Breukink SO (2017) Time trends in the epidemiology and outcome of perianal fistulizing Crohn's disease in a population-based cohort. Eur J Gastroenterol Hepatol 29:595–601

    Article  Google Scholar 

  • Greveson K, Woodward S (2013) Exploring the role of the inflammatory bowel disease nurse specialist. Br J Nurs 22:952–954 956–958

    Article  Google Scholar 

  • Hart AL, Lomer M, Verjee A, Kemp K, Faiz O, Daly A, Solomon J, Mclaughlin J (2017) What are the top 10 research questions in the treatment of inflammatory bowel disease? A priority setting partnership with the James Lind Alliance. J Crohns Colitis 11:204–211

    Article  Google Scholar 

  • Hernandez-Sampelayo P, Seoane M, Oltra L, Marin L, Torrejon A, Vera MI, Garcia V, Lazaro P, Parody E, Blasco AJ, Casellas F (2010) Contribution of nurses to the quality of care in management of inflammatory bowel disease: a synthesis of the evidence. J Crohns Colitis 4:611–622

    Article  Google Scholar 

  • Hvas CL, Dahlerup JF, Jacobsen BA, Ljungmann K, Qvist N, Staun M, Tottrup A (2011) Diagnosis and treatment of fistulising Crohn’s disease. Dan Med Bull 58:C4338

    PubMed  Google Scholar 

  • Irvine EJ, McMaster IBD Study Group (1995) Usual therapy improves perianal Crohn's disease as measured by a new disease activity index. J Clin Gastroenterol 20:27–32

    Article  CAS  Google Scholar 

  • Kariyawasam VC, Ward MG, Blaker PA, Patel KV, Goel R, Sanderson JD, Irving PM (2017) Thiopurines dosed to a therapeutic 6-thioguanine level in combination with adalimumab are more effective than subtherapeutic thiopurine-based combination therapy or adalimumab monotherapy during induction and maintenance in patients with long-standing Crohn's disease. Inflamm Bowel Dis 23:1555–1565

    Article  Google Scholar 

  • Karmiris K, Bielen D, Vanbeckevoort D, Vermeire S, Coremans G, Rutgeerts P, Van Assche G (2011) Long-term monitoring of infliximab therapy for perianal fistulizing Crohn's disease by using magnetic resonance imaging. Clin Gastroenterol Hepatol 9:130–136

    Article  CAS  Google Scholar 

  • Kasparek MS, Glatzle J, Temeltcheva T, Mueller MH, Koenigsrainer A, Kreis ME (2007) Long-term quality of life in patients with Crohn's disease and perianal fistulas: influence of fecal diversion. Dis Colon Rectum 50:2067–2074

    Article  Google Scholar 

  • Keshaw H, Foong KS, Forbes A, Day RM (2010) Perianal fistulae in Crohn's disease: current and future approaches to treatment. Inflamm Bowel Dis 16:870–880

    Article  Google Scholar 

  • Kosmidis C, Anthimidis G (2011) Emergency and elective surgery for small bowel Crohn's disease. Tech Coloproctol 15(Suppl 1):S1–S4

    Article  Google Scholar 

  • Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS, ACPGBI Perianal Crohn's Disease Group (2017a) Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn's disease. Color Dis 19:418–429

    Article  CAS  Google Scholar 

  • Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS, pCD Collaborators (2017b) Surgical management of fistulating perianal Crohn's disease: a UK survey. Color Dis 19:266–273

    Article  CAS  Google Scholar 

  • Lloyd DA, Gabe SM, Windsor AC (2006) Nutrition and management of enterocutaneous fistula. Br J Surg 93:1045–1055

    Article  CAS  Google Scholar 

  • Manne A, Ahmed MB, Malik TA (2016) Predictors of outcome of Rectovaginal fistula surgery in women with Crohn's disease. J Clin Med Res 8:126–129

    Article  Google Scholar 

  • Mcnair AG, Heywood N, Tiernan J, Verjee A, Bach SP, Fearnhead NS, ORACLE Collaboration (2017) A national patient and public colorectal research agenda: integration of consumer perspectives in bowel disease through early consultation. Color Dis 19:O75–O85

    Article  CAS  Google Scholar 

  • Milito G, Lisi G, Venditti D, Campanelli M, Aronadio E, Grande M (2017) Surgical treatment of rectovaginal fistula in Crohn's disease: a tertiary center experience. Surg Technol Int 30:113–116

    PubMed  Google Scholar 

  • Molendijk I, Peeters KC, Baeten CI, Veenendaal RA, Van Der Meulen-De Jong AE (2014) Improving the outcome of fistulising Crohn's disease. Best Pract Res Clin Gastroenterol 28:505–518

    Article  Google Scholar 

  • Morar P, Read J, Arora S, Hart A, Warusavitarne J, Green J, Sevdalis N, Edwards C, Faiz O (2015) Defining the optimal design of the inflammatory bowel disease multidisciplinary team: results from a multicentre qualitative expert-based study. Frontline Gastroenterol 6:290–297

    Article  Google Scholar 

  • Mullen R, Deveraj S, Suttie SA, Matthews AG, Yalamarthi S (2011) MR imaging of fistula in ano: indications and contribution to surgical assessment. Acta Chir Belg 111:393–397

    Article  CAS  Google Scholar 

  • Nanda KS, Cheifetz AS, Moss AC (2013) Impact of antibodies to infliximab on clinical outcomes and serum infliximab levels in patients with inflammatory bowel disease (IBD): a meta-analysis. Am J Gastroenterol 108:40–47 quiz 48

    Article  CAS  Google Scholar 

  • Nasseri Y, Cassella L, Berns M, Zaghiyan K, Cohen J (2016) The anal fistula plug in Crohn's disease patients with fistula-in-ano: a systematic review. Color Dis 18:351–356

    Article  CAS  Google Scholar 

  • Nielsen OH, Rogler G, Hahnloser D, Thomsen OO (2009) Diagnosis and management of fistulizing Crohn's disease. Nat Clin Pract Gastroenterol Hepatol 6:92–106

    Article  Google Scholar 

  • Nunes J, Santos PM, Tavares L (2010) Complete resolution of enterocolic fistulas with infliximab. BioDrugs 24(Suppl 1):28–30

    Article  Google Scholar 

  • Panes J, Garcia-Olmo D, Van Assche G, Colombel JF, Reinisch W, Baumgart DC, Dignass A, Nachury M, Ferrante M, Kazemi-Shirazi L, Grimaud JC, de la Portilla F, Goldin E, Richard MP, Leselbaum A, Danese S, Collaborators ACSG (2016) Expanded allogeneic adipose-derived mesenchymal stem cells (Cx601) for complex perianal fistulas in Crohn's disease: a phase 3 randomised, double-blind controlled trial. Lancet 388:1281–1290

    Article  Google Scholar 

  • Panes J, Rimola J (2017) Perianal fistulizing Crohn's disease: pathogenesis, diagnosis and therapy. Nat Rev Gastroenterol Hepatol 14(11):652

    Article  Google Scholar 

  • Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63:1–12

    Article  CAS  Google Scholar 

  • Pearson DC, May GR, Fick GH, Sutherland LR (1995) Azathioprine and 6-mercaptopurine in Crohn disease. A meta-analysis. Ann Intern Med 123:132–142

    Article  CAS  Google Scholar 

  • Poritz LS, Gagliano GA, Mcleod RS, Macrae H, Cohen Z (2004) Surgical management of entero and colocutaneous fistulae in Crohn's disease: 17 year's experience. Int J Color Dis 19:481–485 discussion 486

    Article  Google Scholar 

  • Poritz LS, Rowe WA, Koltun WA (2002) Remicade does not abolish the need for surgery in fistulizing Crohn's disease. Dis Colon Rectum 45:771–775

    Article  Google Scholar 

  • Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, Van Hogezand RA, Podolsky DK, Sands BE, Braakman T, Dewoody KL, Schaible TF, van Deventer SJ (1999) Infliximab for the treatment of fistulas in patients with Crohn's disease. N Engl J Med 340:1398–1405

    Article  CAS  Google Scholar 

  • Sampietro GM, Casiraghi S, Foschi D (2013) Perforating Crohn's disease: conservative and surgical treatment. Dig Dis 31:218–221

    Article  Google Scholar 

  • Sanchez-Guillen L, Lopez De Los Reyes R, Vives-Rodriguez E, Mato Iglesias A, Canton-Blanco A (2016) Enteral nutrition in Crohn's disease with a high output enteroatmospheric fistula. Cir Esp 94:547–550

    Article  Google Scholar 

  • Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB, American Gastroenterological Association Clinical Practice Committee (2003) AGA technical review on perianal Crohn's disease. Gastroenterology 125:1508–1530

    Article  Google Scholar 

  • Sands BE, Anderson FH, Bernstein CN, Chey WY, Feagan BG, Fedorak RN, Kamm MA, Korzenik JR, Lashner BA, Onken JE, Rachmilewitz D, Rutgeerts P, Wild G, Wolf DC, Marsters PA, Travers SB, Blank MA, van Deventer SJ (2004) Infliximab maintenance therapy for fistulizing Crohn's disease. N Engl J Med 350:876–885

    Article  CAS  Google Scholar 

  • Sauk J, Nguyen D, Yajnik V, Khalili H, Konijeti G, Hodin R, Bordeianou L, Shellito P, Sylla P, Korzenik J, Friedman S, Ananthakrishnan AN (2014) Natural history of perianal Crohn's disease after fecal diversion. Inflamm Bowel Dis 20:2260–2265

    Article  Google Scholar 

  • Schreiber S, Lawrance IC, Thomsen OO, Hanauer SB, Bloomfield R, Sandborn WJ (2011) Randomised clinical trial: certolizumab pegol for fistulas in Crohn's disease - subgroup results from a placebo-controlled study. Aliment Pharmacol Ther 33:185–193

    Article  CAS  Google Scholar 

  • Schwartz DA, Ghazi LJ, Regueiro M, Fichera A, Zoccali M, ONG EM, Mortele KJ, Crohn's & Colitis Foundation of America, Inc. (2015) Guidelines for the multidisciplinary management of Crohn's perianal fistulas: summary statement. Inflamm Bowel Dis 21:723–730

    Article  Google Scholar 

  • Schwartz DA, Loftus EV Jr, Tremaine WJ, Panaccione R, Harmsen WS, Zinsmeister AR, Sandborn WJ (2002) The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota. Gastroenterology 122:875–880

    Article  Google Scholar 

  • Siegmund B, Feakins RM, Barmias G, Ludvig JC, Teixeira FV, Rogler G, Scharl M (2016) Results of the fifth scientific workshop of the ECCO (II): pathophysiology of perianal Fistulizing disease. J Crohns Colitis 10:377–386

    Article  Google Scholar 

  • Singh B, Mortensen NJM, Jewell DP, George B (2004) Perianal Crohn's disease. Br J Surg 91:801–814

    Article  CAS  Google Scholar 

  • Solomon MJ (1996) Fistulae and abscesses in symptomatic perianal Crohn's disease. Int J Color Dis 11:222–226

    Article  CAS  Google Scholar 

  • Stidham RW, Cross RK (2016) Endoscopy and cross-sectional imaging for assessing Crohns disease activity. Tech Gastrointest Endosc 18:123–130

    Article  Google Scholar 

  • Thomassin L, Armengol-Debeir L, Charpentier C, Bridoux V, Koning E, Savoye G, Savoye-Collet C (2017) Magnetic resonance imaging may predict deep remission in patients with perianal fistulizing Crohn's disease. World J Gastroenterol 23:4285–4292

    Article  Google Scholar 

  • Thompson MJ, Epanomeritakis E (2008) An accountable fistula management treatment plan. Br J Nurs 17:438–440

    Article  Google Scholar 

  • Tiernan J, Cook A, Geh I, George B, Magill L, Northover J, Verjee A, Wheeler J, Fearnhead N (2014) Use of a modified Delphi approach to develop research priorities for the association of coloproctology of Great Britain and Ireland. Color Dis 16:965–970

    Article  CAS  Google Scholar 

  • Tozer P, Borowski DW, Gupta A, Yassin N, Phillips R, Hart A (2015) Managing perianal Crohn's fistula in the anti-TNFalpha era. Tech Coloproctol 19:673–678

    Article  CAS  Google Scholar 

  • Tozer PJ, Burling D, Gupta A, Phillips RK, Hart AL (2011) Review article: medical, surgical and radiological management of perianal Crohn's fistulas. Aliment Pharmacol Ther 33:5–22

    Article  CAS  Google Scholar 

  • Van Assche G, Vanbeckevoort D, Bielen D, Coremans G, Aerden I, Noman M, D'hoore A, Penninckx F, Marchal G, Cornillie F, Rutgeerts P (2003) Magnetic resonance imaging of the effects of infliximab on perianal fistulizing Crohn's disease. Am J Gastroenterol 98:332–339

    Article  Google Scholar 

  • Yassin NA, Askari A, Warusavitarne J, Faiz OD, Athanasiou T, Phillips RK, Hart AL (2014) Systematic review: the combined surgical and medical treatment of fistulising perianal Crohn's disease. Aliment Pharmacol Ther 40:741–749

    Article  CAS  Google Scholar 

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Correspondence to Nicola S. Fearnhead .

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Fearnhead, N.S. (2019). Penetrating Crohn’s Disease and Fistulae. In: Sturm, A., White, L. (eds) Inflammatory Bowel Disease Nursing Manual. Springer, Cham. https://doi.org/10.1007/978-3-319-75022-4_20

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  • DOI: https://doi.org/10.1007/978-3-319-75022-4_20

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