Management of Complex Anorectal and Perianal Crohn's Disease

Abstract

Perianal symptoms occur in up to 50% of patients with Crohn's disease in other parts of the gastrointestinal tract, and in 5% of patients it is the first manifestation of the disease. The perianal area is often under stress in patients with Crohn's disease, because of the diarrhea, and the fecal urgency, frequency, and incontinence caused by proximal disease. Symptomatic perianal disease can therefore be due to the effects of the stress on an otherwise normal anus, or the result of Crohn's disease in the low rectum and/or perianal tissues themselves. This key distinction should drive the investigation and management of anal and perianal symptoms in patients with Crohn's disease. In this review, the evaluation and management of the various manifestations of Crohn's disease in the perineum and perianal tissues will be described.

Keywords: anal fissure; anorectal fistula; perianal Crohn's disease.

Fig. 1

Perineal Crohn's disease: a fistulotomy wound over a year after it was made. There has been no healing. There are edematous tags and a painless fissure in the anus.

Fig. 2

Perianal Crohn's disease. A 33-year-old woman with bluish colorectal of perianal skin, an anterior hooded tag concealing the internal opening of a fistula, a posterior fissure with a sentinel tag, and an abscess in the left anterior perineum.

Fig. 3

Drainage of a large perianal abscess in a patient with Crohn's disease: use of counter incisions with Penrose drains to gain control of the sepsis. There are two vessel-loop setons and one mushroom catheter draining a cavity.