Multidisciplinary management of perianal Crohn's disease

Abstract

Purpose of reviewMultiple new medications with novel mechanisms of action are now available to treat Crohn's disease (CD). However, they have varying effectiveness in the management of perianal CD. Identifying the most appropriate therapy and optimizing it is essential to maximize effectiveness of therapy. Additionally, the management of perianal CD requires imaging of the perianal area to identify the fistula anatomy and local complications such as abscesses that require surgical drainage. Initial surgical assessment is key to drain abscesses and allow fistula healing with medical therapy. Recent findingsAlthough anti-tumor necrosis factor (TNFs) remain the most effective medications to treat perianal CD, realworld data suggests that ustekinumab may be a 2 nd -line option in patients nonresponsive to an anti-TNF or having contraindications. Mesenchymal stem cells are an emerging therapeutic approach that is currently in Phase 3 trials in the United States and poised to play a major role in the treatment algorithm.

Radiologist Performance and Reliability of MR Scoring Systems in Perianal Fistulizing Crohn’s Disease: Retrospective Analysis in a Real-World Clinical Practice

“…CD-PAF patients have limited therapeutic options and reduced quality of life [5]. Despite medical treatment with biologics and surgical seton placement, remission is achieved in only a third of patients at 1 year, and many experience recurrence within 2 years due to poorly characterized treatment responses [5]. Given this clinical landscape, measuring improvement in perianal fistulas on MR has become increasingly integrated into CD-PAF clinical trials [21, 22].…”

“…Magnetic resonance imaging (MRI) of the pelvis is the standard of care in assessment of perianal fistulizing Crohn's disease (CD-PAF) [4]. MR interpretations of perianal fistulas are pivotal in guiding and evaluating the response to medical management and surgical planning [5]. Furthermore, radiological healing or remission beyond clinical cessation of drainage is a recent concept [6,7] in managing CD-PAF where fistula tracts that are persistent on MR despite apparent clinical closure [8] have higher relapse rates [9] and need for therapeutic interventions [10].…”

Perineal hernia as a sequela of anal reconstruction surgeries in perianal Crohn's disease

“…Previously described presentations on imaging utilized contrast-enhanced CT, which showed protrusion of abdominal contents into the perineum, including 1 study which portrayed CT findings of perineal hernia in a patient with a history of abdominoperineal exenteration and inferior gluteal artery perforator flap surgery [ 7 , 9 ]. Although contrast-enhanced CT can help establish the diagnosis, MRI with enterography may have more clinical utility in pCD patients due to its ability to assess for pCD treatment response and detect concurrent active pCD and fistulas [10] . Patients with pCD may undergo surgeries such as LIFT and endorectal flap advancement surgeries for complex anal fistula treatment [11] .…”

Management of Perianal Crohn's Disease

“…There have been great advances in the medical management of CD-PAF with multiple new medications with novel mechanisms of action. Anti-TNF agents, especially infliximab, with or without antibiotics and immunomodulators, seem to have the most robust data supporting their use first line in CD-PAF (66,67). Our proposed algorithm to guide management is presented in Figure 2.…”