GASTROENTEROLOGY ARTICLE OF THE WEEK
February 12, 2004
AGA. American Gastroenterological Association Medical Position Statement: Perianal Crohn’s Disease. Gastroenterology 2003;125:1503-1507
1. Features of a complex fistula include
a. “high” location
b. single external opening
c. associated perirectal abscess or severe pain
d. associated with rectovaginal fistula
e. associated with anorectal stricture
2. Treatment of Crohn’s perianal fistulas
a. controlled trials have established the efficacy of antibiotics for this condition
b. when antibiotics are used, treatment duration should be 3-4 months
c. azathioprine has been shown to be effective in achieving fistula closure in
randomized prospective controlled trials
d. a 3-dose induction regimen of infliximab has been shown effective in reducing
the number of fistulas
e. cyclosporine is a proven alternative for patients with fistulas not responding to other therapies.
3. A noncutting seton is a:
a. dull surgical blade
b. procedure to decrease the risk of abscess formation
c. dull pair of scissors
d. procedure to filet-open the fistula
e. procedure to promote fistula drainage
4. Vaginal delivery should be avoided in
a. all patients with Crohn’s disease
b. patients with Crohn’s disease involving the colon only
c. patients with active perianal disease
d. patients with a prior history of perianal disease who are currently
asymptomatic
True or False
5. Surgical repair of rectovaginal fistulas in patients with perineal Crohn’s disease should only be attempted in the absence of active inflammation of the rectosigmoid.
6. Perianal fistulas are most common in patients with rectal involvement and least common in patients with only ileal or ileocolic Crohn’s and rectal sparing.
7. Fistulas are classified as high or low depending on their relation to the dentate line.
8. The presence of a perianal fistula in Crohn’s disease implies active anal canal or rectal mucosal disease with ulcerations.
9. Large perianal skin tags or hemorrhoids in patients with Crohn’s disease should be surgically removed to prevent infection and fistula formation.
10. Fistulography and CT scans are not useful in diagnosis and classifying perianal fistulas
11. Fistulotomy of a high fistula is not recommended due to a high incidence of fecal incontinence.
12. Use of a noncutting seton rather than fistulotomy is recommended for patients with low or high fistulas and active inflammation of the rectum.
13. Examination under anesthesia and pelvic MRI or anorectal EUS + exam under anesthesia change surgical management in over 80% of cases.
14. Anal fissures in patients with Crohn’s disease rarely heal unless treated with high dose corticosteroids.
15. Simple low fistulas that do not respond to antibiotics and are not associated with active rectosigmoid inflammation are probably best managed with fistulotomy
16. Recurrence rates are high after treating complex fistulas surgically, infliximab is the treatment of choice for these types of fistulas