Anorectal Crohn's Disease

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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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