Management of perianal Crohn’s disease

Abstract

Perianal manifestations of Crohn's disease usually coexist with active inflammation of other primary sites of the disease. Although treatment of active proximal disease may sometimes alleviate perianal symptoms, it is reasonable to separately treat symptomatic perianal disease. The diversity of perianal manifestations in Crohn's disease mandates a tailored, individualized approach in every case. Medical therapy is the best treatment option for hemorrhoids and anal fissures. The medical management of patients with perianal Crohn's disease includes the use of systemic antibiotics, immunosuppressive agents, and infliximab. Infliximab is now recognized as a very efficacious agent for treating fistulizing Crohn's disease, including perianal fistulae. It may also reduce the need for surgical intervention in specific cases. Abscesses and fistulae are treated by control of sepsis, resolution of inflammation and optimal preservation of continence, and quality of life. Abscesses require surgical drainage that may need to be prolonged to achieve complete healing. Fistulae may be treated medically, especially in cases of concurrent proctitis. Refractory fistulae may require surgical treatment including an occasional need for fecal diversion or proctectomy. The role of new treatment options such as natalizumab and CDP571 is evolving and requires further investigation.

Perianal Crohn's Disease

“…5 The following are general principles that apply to all types of perianal disease. 14 The control of diarrhea by dietary changes and medication may reduce perianal symptoms. Cleansing may relieve some of the itching and pain associated with perianal lesions.…”

Loose Seton Technique as a Conventional Procedure for the Treatment of Anal Fistula and Long-Term Results

“…Nevertheless, some surgeons continue to use this method. The other method, namely the loose seton technique is performed by passing seton through the fistula tract and leaving it loose without tightening in patients with a high risk of incontinence, perianal Crohn's disease patients and in patients with severe perianal sepsis [8]. Since the primary function of loose seton is drainage and not cutting the anal sphincter, anal incontinence is less common with this technique [4].…”

Multimodality Approaches to Improving Post-operative Pain and Outcomes

“…16 The underlying pathology of POI is best described as a lack of co-ordinated bowel motility that affects all segments of the GI tract. 16,18 Small bowel motility usually recovers within hours of surgery, 16,18,19 gastric motility typically recovers within 24-48 hours post-operatively, 9,21 and recovery of colonic motility, which is generally the limiting factor in resolving POI, usually occurs 48-72 hours post-operatively. [16][17][18][19][20]22 Development of POI is multifactorial.…”

“…• Decreased GI secretions 21 • Increased contraction of GI sphincters 21 Disorganized GI electrical activity 19,35 • Irregular gastric spike and slow-wave activity (stomach) 16 • Shortened and/or retrograde MMC (small bowel) 16,18,19 Pro-inflammatory mediators and cytokines 13,35,[106][107][108][109] • Activated macrophages release:…”