How are we managing fistulating perianal Crohn's disease? Results of a national survey of consultant gastroenterologists

Abstract

Objective: Fistulating perianal Crohn's disease represents a significant challenge to both clinicians and patients. This survey set out to describe current practice and variation in the medical management of this condition.

Design: A survey was designed by an expert group of gastroenterologists and surgeons with an inflammatory bowel disease (IBD) interest. The questionnaire aimed to capture opinions from consultant gastroenterologists with a UK practice on the management of acutely symptomatic fistula, assessment of a new fistula presentation, medical management strategies and surgical intervention. The survey was piloted at the British Society of Gastroenterology Clinical Research Group meeting, and distributed at UK gastroenterology meetings.

Results: There were 111 completed responses (response rate 55%). Following clearance of sepsis, 22.1% of respondents would wait 6 weeks or more before commencing medical therapy. Antibiotics were used by 89.2%, with a variable duration. First-line medical therapy was thiopurine for 48% and antitumour necrosis factor (TNF) for 50% of respondents. These were used in combination by 44.4%. Interval to escalation of therapy (if required) varied from 1 month to a year. Anti-TNF therapies were favoured in deteriorating patients. An IBD multidisciplinary team was accessible to 98%, although only 23.6% routinely discussed these patients. Optimisation strategies for anti-TNF and thiopurines were used by 70% of respondents. Recurrent sepsis, refractory disease and patient choice are indications for surgical referral.

Conclusion: These results illustrate the huge variation in practice and lack of consensus among physicians for the optimal medical management of perianal Crohn's disease. There are gaps in knowledge that require targeted research.

Keywords: crohn’s disease; gastrointestinal fistulae; health service research.

Figure 1

Minimum tests required for assessment of patient with Crohn’s anal fistula.

Figure 2

Initial medical therapy. TNF, tumour necrosis factor.

Figure 3

Intervals between commencement of therapy, reassessment and escalation.