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Review
. 2022 Jan 17;35(1):51-57.
doi: 10.1055/s-0041-1740038. eCollection 2022 Jan.

A Multi-Disciplinary Approach to Perianal Fistulizing Crohn's Disease

Affiliations
Review

A Multi-Disciplinary Approach to Perianal Fistulizing Crohn's Disease

Jacob Wiseman et al. Clin Colon Rectal Surg. .

Abstract

Perianal fistulizing Crohn's disease represents a severe phenotype associated with significant morbidity. Patients with perianal fistulizing disease are more likely to have a severe disease course and have significant reductions in quality of life. Moreover, these patients are at risk for the development of distal rectal and anal cancers. Given the complexity and severity of this patient group, the management of perianal Crohn's disease must be undertaken by a multidisciplinary team. The gastroenterologist and colorectal surgeon play a critical role in the diagnosis and management of perianal fistulizing disease. An examination under anesthesia provides critical information and is an essential part of the work-up of complex perianal fistulas. The radiologist also plays a central role in characterizing anatomy and assessing response to treatment. Several imaging modalities are available for these patients with magnetic resonance imaging as the imaging modality of choice. Perianal disease developing after ileal pouch-anal anastomosis represents a particularly challenging form of fistulizing disease and requires a multidisciplinary clinical and radiologic approach to differentiate surgical complications from recurrent Crohn's disease.

Keywords: Crohn's disease; examination under anesthesia; inflammatory bowel disease; magnetic resonance imaging; perianal fistula.

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Conflict of interest statement

Conflict of Interest A.V.W. reports the following disclosures: Advisory Board—Abbvie, Takeda, Ferring and Speaker—Abbvie, Janssen. These companies make medical treatments for inflammatory bowel disease. Medical Crohn's treatments were not discussed in this review article. A.d.B.v.O. reports personal fees from Abbvie, outside the submitted work.

Figures

Fig. 1
Fig. 1
A 31-year-old male chronic perianal disease CT images ( a , b ) show multiple tubular low-density tracts in the perianal region with areas of coarse calcification ( arrows ). MRI performed subsequently shows a multiloculated cystic mass ( c , d ) with characteristic double layer enhancement seen with a mucinous adenocarcinoma ( e ).
Fig. 2
Fig. 2
These images display a horseshoe or “complex “fistula. By definition they demonstrate characteristics such as greater involvement of the sphincter complex, multiple openings, an associated collection, or communication with an adjacent structure such as the vagina.
Fig. 3
Fig. 3
Images demonstrating a simple trans-sphincteric tract. Note that the peripheral hypo-intensity indicates some healing/granulation tissue.
Fig. 4
Fig. 4
MRI in a patient with an IPAA procedure shows a fistulous tract ( arrows ) arising from the posterior wall of the pouch between 5 and 6 o'clock. This is seen to have a locule of air on the fat sat T2W images ( a ). It shows avid enhancement on the post gadolinium sequences ( b ). IPAA, ileal pouch-anal anastomosis; MRI, magnetic resonance imaging.

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