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Fistulating Crohn’s disease remains a therapeutic challenge and a considerable burden to many patients. Treatment with agents such as infliximab held great promise but recent reports of life threatening infection are a concern. The combination of occult or undrained sepsis and powerful immunomodulation is not to be taken lightly and, as in other aspects of Crohn’s disease, merits a multidisciplinary approach.

Recognising this, the Oxford group has used a combination of immunosuppression (azathioprine or methotrexate), selective magnetic resonance imaging (MRI) scanning and examination under anaesthetic (EUA), with appropriate drainage of sepsis and insertion of seton sutures followed by early infliximab (seton sutures were removed on the second induction dose at 2 weeks). This study reports the outcome in 22 patients (median age 35, 16 women) with perianal Crohn’s disease. Of the 21 patients who underwent EUA, 12 required abscess drainage and 17 required at least one seton suture insertion. Fourteen patients underwent MRI scanning based on multiple fistula sites or clinical suspicion of occult sepsis. Six of these MRIs indicated areas of abscess that were not clinically obvious.

No serious complication related to infliximab occurred. In particular, there was …