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Gut 63:1381-1392 doi:10.1136/gutjnl-2013-306709
  • Guidelines

A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease

Editor's Choice
  1. for the World Gastroenterology Organization, International Organisation for Inflammatory Bowel Diseases IOIBD, European Society of Coloproctology and Robarts Clinical Trials
  1. 1Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
  2. 2Robarts Research Institute, Amsterdam, The Netherlands
  3. 3Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
  4. 4St. Vincent's Hospital and University of Melbourne, Melbourne, Australia
  5. 5Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
  6. 6Robarts Research Institute, London, Ontario, Canada
  7. 7University of Western Ontario, London, Ontario, Canada
  8. 8Department of Medicine and Therapeutics, Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, Hong Kong
  9. 9Department of Gastroenterology, Hospital Clinic Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
  10. 10Department of Gastroenterology, University of Leuven, Leuven, Belgium
  11. 11Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
  12. 12APRG, Imperial College, London, UK
  13. 13IBD Unit, St. Mark's Hospital, London, UK
  14. 14Robarts Research Institute, San Diego, CA, USA
  15. 15Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
  1. Correspondence to Professor Geert D'Haens, Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands; g.dhaens{at}amc.uva.nl
  • Received 3 January 2014
  • Revised 17 May 2014
  • Accepted 28 May 2014
  • Published Online First 20 June 2014

Abstract

Objective To develop a consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease (pCD), based on best available evidence.

Methods Based on a systematic literature review, statements were formed, discussed and approved in multiple rounds by the 20 working group participants. Consensus was defined as at least 80% agreement among voters. Evidence was assessed using the modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria.

Results Highest diagnostic accuracy can only be established if a combination of modalities is used. Drainage of sepsis is always first line therapy before initiating immunosuppressive treatment. Mucosal healing is the goal in the presence of proctitis. Whereas antibiotics and thiopurines have a role as adjunctive treatments in pCD, anti-tumour necrosis factor (anti-TNF) is the current gold standard. The efficacy of infliximab is best documented although adalimumab and certolizumab pegol are moderately effective. Oral tacrolimus could be used in patients failing anti-TNF therapy. Definite surgical repair is only of consideration in the absence of luminal inflammation.

Conclusions Based on a multidisciplinary approach, items relevant for fistula management were identified and algorithms on diagnosis and treatment of pCD were developed.

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