Modern management of perianal fistulas in Crohn's disease

Olivia is a 32-year-old woman who was diagnosed 6 years ago with mild Crohn’s disease (CD) located in the terminal ileum without colorectal involvement (L1B1 Montreal classification). Remission was induced over a total of 12 weeks using a budesonide 9/6/3mg taper.

Fourteen months ago, Olivia experienced a relapse. At that time, a colonoscopy revealed moderate endoscopic disease activity in the last 15cm of the terminal ileum, with aphthous ulcers and a couple of serpiginous ulcers in the sigmoid portion of the colon. The rectum was unaffected. Remission was induced with budesonide over a total of 12 weeks using a 9/6/3mg taper concomitant with azathioprine (AZA) 2 mg/kg. AZA was continued as maintenance treatment after remission was achieved, and Olivia has tolerated ongoing AZA with no side effects.

Two weeks ago, Olivia presented to the gastroenterologist’s office with new localized pain in the perianal area of 2 weeks’ duration. She denied other symptoms and endorsed normal bowel movements. Her vital signs were normal, and she did not have a fever. Her overall objective (physical) medical status was good. A physical examination of the abdomen was unremarkable, with no pain on palpation. Inspection of the perianal region in the elbow-knee position revealed skin erythema with soft swelling beneath the skin. The swelling was located close to the anal ring at approximately the 5 o’clock position. The swelling was very sensitive and painful on digital palpation. She was diagnosed with a perianal abscess and was immediately referred to an experienced colo-proctologist. The colo-proctologist’s examination is aligned with the gastroenterologist’s findings.

Visit https://med-sims.org/clinic/gastroenterology today to begin Olivia's care.

Lucas is a 28-year-old man with Crohn’s disease (CD) who was diagnosed after presenting to his primary care physician three months ago with pain in the perianal region. Upon questioning, he confirmed that he had been experiencing loose stools and intermittent abdominal pain for the past two months.

Lucas was immediately referred to a gastroenterologist for evaluation of a possible perianal abscess and inflammatory bowel disease. Upon examination of the perianal region, skin erythema with soft swelling beneath the skin was noted. The swelling was located close to the anal ring at approximately the 2 o’clock position. The swelling was very sensitive and painful on digital palpation. The gastroenterologist prescribed a pelvic MRI. They diagnosed a perianal abscess and ordered a colonoscopy, which revealed moderate endoscopic disease activity in the terminal ileum with aphthous ulcers. Stool sample analysis revealed elevated fecal calprotectin levels. Lucas was diagnosed with mild CD of the terminal ileum with a perianal abscess (L1B1p Montreal classification).

Lucas was quickly referred to an experienced colo-proctologist who performed examination under anesthesia (EUA) with surgical drainage of the abscess followed by a course of ciprofloxacin 2 x 500 mg/day for 7 days. No fistula was noted during EUA, which was confirmed via contrast-enhanced pelvic MRI two days post procedure.

Three weeks later, Lucas presents for follow-up with drainage in the perianal region at the 2 o’clock position. An external fistula opening is identified that corresponds to the location of the drained perianal abscess. Contrast-enhanced pelvic MRI reveals a complex high inter-sphincteric fistula with a diameter of about 1.5cm and a track length of about 10cm. No abscesses are visible.

Visit https://med-sims.org/clinic/gastroenterology today to begin Lucas's care.