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Experts release multidisciplinary guideline for management of Crohn's perianal fistulas
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A multidisciplinary panel of experts have written a guideline on the management of perianal fistulas associated with Crohn’s disease, a common manifestation that can result in significant morbidity.
“This publication has been a multi-year effort by all of my co-authors. We wanted to put together a comprehensive multidisciplinary guideline that reflects all of the different subspecialists that are needed to care for patients with this difficult problem,” David A. Schwartz, MD, FACG, AGAF, director of the Inflammatory Bowel Disease Center at Vanderbilt University Medical Center in Nashville, Tennessee, told Healio Gastroenterology. “Patients with perianal CD have a complicated and debilitating manifestation of their IBD. Treatment and imaging options for these patients have improved greatly over the last 5 to 10 years. As a result, outcomes are much better but require a multidisciplinary approach to maximize results and prevent complications.”
David A. Schwartz
Classification
As care of perianal fistulas with CD involves physicians from different subspecialties, including gastroenterologists, radiologists and surgeons, a classification scheme is important for accurate communication, the authors wrote. Several have been developed during the past 40 years, such as the Cardiff system, which was never accepted in widespread clinical practice; the five-category Park’s system, “the most anatomically precise fistula classification system;” and a more recent “user friendly and clinically useful approach” proposed in an American Gastroenterological Association technical review, which categorizes fistulas as simple or complex.
Assessment and treatment
The clinical guidelines proposed for the management of Crohn’s perianal fistulas focus on seven key areas:
- initial assessment/diagnosis and classification;
- outcome measures;
- monitoring of fistula healing;
- philosophy of treatment;
- treatment of simple fistulas;
- treatment of complex fistulas; and
- treatment of rectovaginal fistulas.
Because inflammation and fibrosis can make assessment difficult, the guideline recommends all patients undergo MRI before treatment or anorectal endoscopic ultrasound as an alternative if an expert is available. An accurate perianal process assessment also is important, as well as an examination under anesthesia by an experienced surgeon to improve accuracy and allow for surgical interventions.
Objective measures of fistula activity include the Fistula Drainage Assessment measure, which classifies fistulas as improved or in remission; the Perianal Disease Activity Index, a validated five-category “perianal equivalent to the Crohn’s Disease Activity Index;” and the MRI-based score, which is the only image-based activity measure, thus providing increased objectivity.
Although monitoring of fistula healing has been traditionally based on physical examination, the guideline recommends using MRI or endoscopic ultrasound, especially for complex fistulas. When an “imaging study showed persistent inflammation even if the drainage had ceased, either the seton was left in place and/or medical therapy was escalated,” which improved outcomes “at least out to 1 year,” the authors wrote.
As the goal of treatment is to “achieve complete fistula closures and avoid some of the frequent complications that lead to poor outcomes and negatively affect a patient’s quality of life,” the guideline recommends a “top-down” medical approach with anti-tumor necrosis factor and immunomodulator combination therapy and short-term antibiotics. Different permutations of this approach are proposed in a treatment algorithm based on fistula categorization (simple fistula without rectal inflammation, simple fistula with rectal inflammation and complex fistula).
For simple fistulas without proctitis, medical therapy includes a trial of antibiotics and immunomodulators with or without anti-TNF, and surgery is not mandatory. For simple fistulas with proctitis, combined surgery and medical approach with anti-TNF is recommended or a short trial of rectal 5-aminosalicylic acid or steroids as an alternative.
For complex fistulas, surgery is required along with antibiotics, immunomodulators and anti-TNF, “as the goal of therapy in this setting changes from complete fibrosis of the tract to control of fistula drainage and prevention of abscess formation,” the authors wrote.
Medical management alone is often unsuccessful for rectovaginal fistulas, so they typically have to be treated surgically, most commonly with an endorectal advancement flap. Finally, refractory fistulas are primarily treated surgically with fibrin glue, fistula plug, fecal diversion, proctectomy or proctocolectomy. – by Adam Leitenberger
Disclosure: The researchers report no relevant financial disclosures.
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