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.