Anorectal Crohn's Disease
Section snippets
PREVALENCE
Crohn's disease is a chronic inflammatory condition that may involve the entire alimentary tract, from the mouth to the anus. Three major categories of the disease are recognized: (1) ileocolic (41%–55% of cases), (2) small intestinal (30%–40% of cases), and (3) colonic (14%–26% of cases).67 Perianal or anorectal disease is a primary feature of Crohn's disease, with a prevalence of 8% to 90%, and typically is considered to afflict approximately one in three patients.36, 58, 72, 78 It is seldom
CLINICAL PRESENTATION
Most patients with Crohn's disease present with abdominal pain, diarrhea, and weight loss, but 5% of patients with Crohn's disease present with anal lesions only, and most will develop intestinal symptoms, sometimes many years later.67 The spectrum of anal complaints is great. Fissures and edematous skin tags are most common. Most anal fissures are located in the posterior midline, in the general population, but in patients with Crohn's disease, fissures may occur eccentrically. They are deep
DIAGNOSIS
A thorough physical examination, including a rectal examination, diagnoses most perianal conditions in patients with Crohn's disease, but some patients must be examined under general anesthesia, especially if perianal suppuration and tenderness are present. Also, examination under general anesthesia often is considered an extension of the physical examination in patients with severely painful anorectal disease. For more complex presentations, additional modalities are needed, including barium
TREATMENT
Many patients with anorectal Crohn's disease have disease in other parts of the intestinal tract, which warrants an evaluation of the colon and small bowel. The presence of proximal disease poses a therapeutic dilemma: Early reports suggest that perianal conditions persist in the presence of proximal disease and improve only if proximal disease is resected24, 26; however, other reports refute these findings and show no improvement in perianal disease after treatment of proximal disease.11, 54
Abscess
Several potential anorectal spaces may become infected with an abscess. Briefly, these spaces are categorized as perianal, ischiorectal, deep postanal, intersphincteric, and supralevator. In patients with perianal Crohn's disease, the prevalence of abscesses is approximately 50%.34, 47, 78 Abscesses in these patients may be complex and multiple and often must be evaluated radiographically.
The cause of Crohn's abscesses is not completely understood. Many investigators believe that Crohn's
ROLE FOR PROCTECTOMY
Devastating perianal complications, such as incontinence, anal stenosis, and severe recurrent abscesses and fistulas, may lead to proctectomy if local procedures are unsuccessful. Fortunately, less than 20% of patients with a history of anorectal Crohn's disease require proctectomy.78 The timing of proctectomy must be dictated by patients, at a point when they believe that medical and surgical interventions have been exhausted. Patients need to be psychologically prepared because this surgical
MEDICAL MANAGEMENT
The initial approach to the management of perianal manifestations of Crohn's disease is to identify the location and severity of intestinal disease and to drain active suppuration. Treatment of active inflammation in the distal rectum with topical mesalamine or corticosteroids, or even immunomodulation, improves symptoms in the anus. Attention to perianal hygiene, including sitz baths, postdefacatory cleansing, and skin protection, also is important. Aside from these approaches, the medical
SUMMARY
Anorectal disease affects many patients with Crohn's disease. Clinical manifestations range from asymptomatic skin tags to severe, debilitating perineal destruction and sepsis. Surgical management must be conservative and must focus on draining septic focus, if present; preserving sphincter function; and palliating symptoms. Medical management has shown some success in improving symptoms but has not yet been able to ameliorate most perianal complaints quickly and durably. Many new and exciting
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Cited by (68)
Fistulizing Crohn's disease
2020, Current Problems in SurgeryAnorectal disorders in inflammatory bowel disease
2019, Anorectal Disorders: Diagnosis and Non-Surgical TreatmentsOutcomes after fecal diversion for colonic and perianal Crohn disease in children
2018, Journal of Pediatric SurgeryCitation Excerpt :Classification tree analysis is suited to these situations [27,28]. There are both clinical and laboratory data that implicate a constituent of the fecal stream in perpetuating colonic and perianal CD [9–24]. The use of elemental diets has been associated with disease remission [29,30].
Treatment of perianal Crohn's disease
2017, Seminars in Pediatric SurgeryValue of diffusion weighted MRI in assessment of simple and complicated perianal fistula
2017, Egyptian Journal of Radiology and Nuclear MedicineCitation Excerpt :This case had fistula with large inter-sphincteric abscess with both edema and enhancing inflammatory reaction in the inter-sphincteric space which lowered the conspicuity of internal opening. Focusing only on detection of primary tract, other researchers [32] reported no significant difference in sensitivity, specificity and accuracy between DWI and T2 weighted images. Although these results are consistent with the current study, we found that DWI had slightly less sensitivity in detection in primary tract as compared to TIRM images but without significant statistical difference (p = 0.303).
Current management of perianal Crohn's disease
2017, Current Problems in Surgery
Address reprint requests to John L. Rombeau, MD, Department of Surgery, 4 Silverstein, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104