Dr. Mohsen Towliat
Associate professor
Colorectal Fellowship
Anorectal involvement is seen in 14% to 38%
of patients, Isolated perianal disease seen in
only 5%.
The prevalence of perianal manifestations
increases as the disease progresses distally.
In patients with ileocolic Crohn’s disease, only
15% develop fistulae, but fistulae occur in 92%
of patients with Crohn’s disease involving the
colon and rectum
Crohn’s disease will affect the anus or
perineum in as many as 61%–80% of patients
Manifest itself as a Fissure
Skin tag
Hemorrhoid
Cavitating ulcer
Abscess or fistula
Anovaginal fistula
Anorectal stricture
Carcinoma
Anorectal Abcsess
Abscess or fistula
Fistula
Anal Stenosis
First Therapy
Multiple setons
. In addition, immunomodulators
and biologic agents;
Typically includes: Antibiotics Immunomodulators Biologic agents Used individually Or in combination.
Metronidazole (20 mg/kg/day) for 6–8 weeks
with a healing rate of 50%–56%
But nearly half of patients will experience disease exacerbation
Azathioprine: (2–3 mg/kg/day) or 6-mercaptopurine (1.5 mg/kg/day)
used alone heals 54% of fistulas compared with a 21% healing rate
with placebo.
Three doses of infliximab (5 mg/kg) delivered at 0, 2, and 6 weeks
can promote fistula closure in 55%, as compared with 13% of the
patients treated with placebo, and the median length of time during
which the fistula remains closed is 3 months
However, ciprofloxacin (1000 mg/day) in combination with
infliximab tends to be more effective than infliximab alone
At week 14 the primary objective of the study
was achieved in 29 patients (85%).
A complete fistula response was obtained in
25 patients (74%)
Adverse events occurred in 25 patients (74%)
Number of Patients (%)
Lesion Type
75 (37) Skin tag
38 (19) Fissure
40 (20) Low fistula
12 (6) High fistula
6 (3) Rectovaginal fistula
32 (16) Perianal abscess
8 (4) Ischiorectal abscess
7 (3) Intersphincteric abscess
6 (3) Supralevator abscess
19 (9) Anorectal stricture
15 (7) Hemorrhoids
12 (12) Anal ulcer
110 (54) Total
Skin Tags
• Present in 40% to 70% of
patients can be difficult to
differentiate from hemorrhoids
• Surgical excision should be
avoided unless they interfere
with hygiene or are persistently
symptomatic
Hemorrhoids :
• Only 7% of patients with Crohn’s disease,
24% in the general population.
• Often asymptomatic, symptoms can be exacerbated by the
severe diarrhea of Crohn’s disease
• In highly selective patients without any active anorectal
Crohn’s manifestations, hemorrhoidectomy can be
successful in up to 88% of patients, either with simple
hemorrhoidectomy or elastic banding
Up to 19% of patients with Crohn’s disease
Crohn’s disease can be eccentrically located in up to
20%
As 40% to 85% of all fissures in patients with Crohn’s
disease present with pain
Painful fissures in a patient with Crohn’s disease should
prompt an examination for underlying abscess or fistula
Should be medical management including:
Nitroglycerin paste
Calcium channel blockers
Botulinum toxin
Successful in up to 80% of cases
In the case of nonhealing symptomatic fissure, proctitis should
be R/O
In patients with persistent fissures without proctitis
Fleshner found that (88%) patients healed after sphincterotomy
(26%) patients who received medical treatment only
developed abscesses or fistulae.
However, in the presence of proctitis surgery should be
avoided.
Twelve percent of patients with Crohn’s disease
present with large, cavitating anal or rectal ulcers
Local treatment, including debridement and
intralesional corticosteroid injection can be
effective
But patients often ultimately require proctectomy
Anus (34%) or the Rectum (50%)
Symptoms are typically functional: difficulty with defecation,
tenesmus, incontinence, or urgency.
In the absence of symptoms, no treatment is necessary
If symptomatic, anal dilatation with a single finger or a coaxial
balloon is effective
Most patients with anal or rectal strictures have concomitant
proctitis, and up to 43% require proctectomy.
Anal Stenosis
Trans position flap for anoplasty
Trans position flap for anoplasty
The most common presentations of anorectal
Crohn’s disease
26% of patients present with an abscess,
frequently complex (intersphincteric,
supralevator, or ischiorectal)
And an additional 29% present with a fistula
Simple: superficial, inter or trans-sphincteric
fistula below the dentate line, with a single
opening and no anorectal stricture or abscess
Complex: trans-, supra-, or extrasphincteric
fistula
above the dentate line, or a fistula with
multiple external openings.
Associated:
- With abscess
- Stricture
- Rectovaginal fistula
Fistulae associated with Crohn’s disease
Require more than a digital rectal exam
Traditionally (EUA) has been the gold standard
( 90% )
Combined (EUS) and pelvic (MRI) Accuracy was
100%
With the use of three-dimensional reconstruction
Some investigators have shown that the results
of EUS are comparable with MRI
Hydrogen peroxide injection in the fistula tract
during EUS substantially improves accuracy
Setons can be left in place long-term without consequence,
And removal without definitive therapy results in recurrence of
the fistula in 20% to 80% of cases.
Fistulotomy offers the best chance for definitive treatment of
perianal fistulas.
Low perianal fistula, with most reporting healing rates between
80% and 100%
Absence of rectal inflammation, results were even better, with
healing in 22/24 (95%) of patients, and recurrence in only 4/24
(15%)
Active proctitis at the time of surgery documented a healing rate
of only 27%
HIGH FISTULA
HIGH FISTULA
HIGH FISTULA
Anal fistula
Patients with complex fistulas or fistulas involving a
significant portion of the anal sphincter complex are at risk of
iatrogenic injury to the sphincter
Fibrin glue and anal fistula plugs have been developed.
Success using fibrin glue has been mixed, with 60% to 78%
Anal plug in Crohn’s disease 44% success
Simple fistulae healed, but only 14% to 50% of complex
fistulae healed in patients without Crohn’s disease
A high perianal fistula:
Branched ramifying tracts
Associated abscess
Multiple external openings define more
complex fistulae
First-line therapy is infliximab
Excellent results in multiple perianal fistula
Combined surgical therapy with temporary placement
of a loose seton at the time of induction has resulted in
healing in 47% to 67% of cases.
Fistulotomy is not recommended in patients with
complex perianal fistulae
Nonhealing and incontinence in 40% to 60%
Many of whom eventually required proctectomy
A loose seton can be left indefinitely,
however, without significant effect on continence.
In the absence of proctitis, a transanal
advancement flap may be a good option.
Up to 20% of patients with perianal Crohn’s
disease eventually require proctectomy.
A transanal sleeve advancement flap has also
been shown to
result in healing in 62% of cases, with a
recurrence rate of 38%
The combined use of infliximab and transanal
advancement flap was shown to improve rates
of healing and decrease time to healing
Pouches fail in 36% to 55% of patients with Crohn’s disease,
most commonly because of leaking at the anastomosis
Azathioprine combined with infliximab improved pouch
perineal fistulae in 85% of patients in 1 small series
Local advancement flaps can improve as many as 50% of cases
with perianal fistulae, but 3% to 6% of patients require pouch
excision and permanent ileostomy
In patients with complex perianal Crohn’s disease, it is the
authors’ practice to combine a pelvic MRI with EUA and rigid
proctoscopy to evaluate for rectal inflammation.
In the presence of a fistula, a noncutting seton made of an inert
material can be placed to prevent recurrence and facilitate
drainage, with healing or improvement seen in 79% to 100% of
patients.
Setons can be left in place long-term without consequence, and
removal without definitive therapy results in recurrence of the
fistula in 20% to 80% of cases.