GASTROENTEROLOGY ARTICLE OF THE WEEK
September 11, 2003
Present DH. Crohn’s fistula: Current concepts in management. Gastroenterology 2003;124:1629-1635.
1. Perianal fistula
a. Is never the initial presentation of Crohn’s disease
b. Is more common with ileal disease compared to colonic disease
c. Occurs in approximately 50% of patients with Crohn’s disease
d. Risk of perianal fistula is increased if there is active disease in the rectum
2. Antibiotic treatement for the treatment of fistulas
a. Metronidazole has an acceptable success rate with a high recurrence rate
upon discontinuation of therapy.
b. Metronidazole neuropathy is rare if the dose is kept below 750mg daily
c. Ciprofloxacin is ineffective in the treatment of Crohn’s fistulas
d. When fistulas respond to antibiotics, relapse is almost universal when
antibiotics are stopped.
True or False
3. Methotrexate, 25mg weekly IM should be considered for patients with perianal fistulas who cannot tolerate 6MP
4. Corticosteroids should not be used in the treatment of Crohn’s disease in patients who have either internal or external fistulas.
5. Perianal fistulas usually arise in the small intestine and track down to the perineum.
6. Infliximab results in fistula closure in about 55% of patients, maintenance is probably required to prevent recurrence.
7. Patients with internal fistulas tend to have a more “virulent” course of Crohn’s disease.
8. CT scanning is not particularly helpful for defining perianal fistulas, MRI, EUS and exam under anesthesia are the three preferred methods.
9. Mesalamine is a useful agent in healing perianal fistulas.
10. 6-MP or azathioprine should be the initial drug of choice to try and close perianal fistulas.
11. 6MP is able to close about 40% of enterovesical fistulas.
12. Infliximab should be the intial therapy of choice for perianal fistulas.
13. Cyclosporin for Crohn’s disease
a. is very effective when used initially at high dose, IV
b. rarely maintains remission when switched to oral regimen
c. Low dose <5mg/kg is not effective
d. Can be used as a bridge until 6MP kicks in
e. takes about 1-2 months to see a response with cyclosporine therapy