Modern Management of Perianal Crohn's Disease: A Review.

Perianal Crohn's disease (CD) is a complex manifestation of CD that affects approximately 10% of patients. The spectrum of disease is quite variable, ranging from relatively mild disease to severe, aggressive manifestations that result in frequent hospitalizations, multiple surgeries, and poor quality of life. Despite significant recent advances in surgical and medical management, treatment remains challenging and frequently requires a multidisciplinary medical-surgical approach. The goal of this article is to review the current literature regarding the work-up, treatment, and future directions of therapy. Crucial features of effective management include the precise identification of manifestations, control of sepsis, limiting rectal inflammation, frequently with use of antitumor necrosis factor agents, and avoidance of extensive surgery.

The London Classification: Improving Characterization and Classification of Anorectal Function with Anorectal Manometry.

PURPOSE OF REVIEW: Objective measurement of anorectal sensorimotor function is a requisite component in the clinical evaluation of patients with intractable symptoms of anorectal dysfunction. Regrettably, the utility of the most established and widely employed investigations for such measurement (anorectal manometry (ARM), rectal sensory testing and the balloon expulsion test) has been limited by wide variations in clinical practice. RECENT FINDINGS: This article summarizes the recently published International Anorectal Physiology Working Group (IAPWG) consensus and London Classification of anorectal disorders, together with relevant allied literature, to provide guidance on the indications for, equipment, protocol, measurement definitions and results interpretation for ARM, rectal sensory testing and the balloon expulsion test. The London Classification is a standardized method and nomenclature for description of alterations in anorectal motor and sensory function using office-based investigations, adoption of which should bring much needed harmonization of practice.

Magnetic Resonance Imaging of Fistula-In-Ano.

This article explains the pathogenesis of fistula-in-ano and details the different classifications of fistula encountered, describe their features on MR imaging, and explains how imaging influences subsequent surgical treatment and ultimate clinical outcome. Precise preoperative characterization of the anatomic course of the fistula and all associated infection via MR imaging is critical for surgery to be most effective. MR imaging is the preeminent imaging modality used to answer pertinent surgical questions.

Treatment of perianal Crohn's disease.

Perianal Crohn's is a common manifestation of Crohn's disease. Primary manifestations of perianal disease mirror common anorectal conditions, however treatment is less successful than in those patients without Crohn's related perianal disease. A multimodal approach to therapy including medical and surgical modalities is often necessary. The goal of treatment is to manage symptoms while maintaining continence.

Transperineal Ultrasound for Perianal Fistulas and Abscesses - A Systematic Review and Meta-Analysis.

Purpose Transperineal ultrasound (TPUS) is a practical tool for assessing perianal inflammatory lesions. We systematically review its accuracy for detecting and classifying perianal fistulae and abscesses. Method The National Library of Medicine and Embase were searched for articles on TPUS for the assessment of idiopathic and Crohn's perianal fistulae and abscesses. Two reviewers independently reviewed eligible studies and rated them for quality using the QUADAS tool. The primary outcome measure was the accuracy of TPUS as measured by its sensitivity and positive predictive value (PPV) in detecting and classifying perianal fistulae, internal openings and perianal abscesses. Results We included 12 studies (565 patients). Overall, the methodological quality of the studies was suboptimal. 3 studies were retrospective and 4 showed significant risks of bias in the application of the reference standard. The sensitivity of TPUS in detecting perianal fistulae on a per-lesion basis was 98 % (95 % CI 96 - 100 %) and the PPV was 95 % (95 % CI 90 - 98 %). The detection of internal openings had a sensitivity of 91 % (95 % CI 84 - 97 %) with a PPV of 87 % (95 % CI 76 - 95 %). The classification of fistulae yielded a sensitivity of 92 % (95 % CI 85 - 97 %) and a PPV of 92 % (95 % CI 83 - 98 %). TPUS had a sensitivity of 86 % (95 % CI 67 - 99 %) and PPV of 90 % (95 % CI 76 - 99 %) in the detection of perianal abscesses. Conclusion The current literature on TPUS illustrates good overall accuracy in the assessment of perianal fistulae and abscesses. However, many studies had methodological flaws suggesting that further research is required.

Treatment-Based Three-Dimensional Classification and Management of Anorectal Infections.

This article provides a current overview on clinical anatomy, pathophysiology, workup and surgical management of anorectal abscesses. Based on the three-dimensional nature of anorectal abscesses, a novel treatment-based classification is proposed. It examines the basis of a philosophic shift from simple drainage to concomitant definitive treatment of abscesses and their underlying primary fistulous trajectories. Complications are discussed specifically in this context.

Evaluation and management of perianal abscess and anal fistula: a consensus statement developed by the Italian Society of Colorectal Surgery (SICCR).

Perianal sepsis is a common condition ranging from acute abscess to chronic fistula formation. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. The key to successful treatment is the eradication of the primary track. As surgery may lead to a disturbance of continence, several sphincter-preserving techniques have been developed. This consensus statement examines the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

[Acute periproctal abscesses]. / Akutní periproktální abscesy.

Periproctal inflammations related to the anus are characterized by the rapid spread of the infection to the surrounding tissue, which is determined by the anatomical characteristics and infectious agents. Inflammation, which starts as a phlegmon, quickly forms boundaries and an abscess develops in most cases. Up to 80-90% of anorectal abscesses develop according to the crypto-glandular theory on the basis of infection of the anal glands, spilling into the Morgagni crypts in the anal canal. Up to two-thirds of such abscesses are associated with the emergence of anorectal fistulas. Anorectal abscesses can be divided into marginal and subcutaneous perianal abscesses, submucosal, intersphincteric, ischiorectal and supralevator abscesses. Their diagnosis is based on thorough physical examination, sometimes also with the help of imaging methods such as computed tomography, magnetic resonance imaging and endoanal ultrasound. What is decisive for the successful treatment of anorectal abscessess is their early and adequate surgical drainage. Adjuvant antibiotic therapy is necessary only when the overall signs of sepsis are present and for patients with a comorbidity such as diabetes, valvular heart disease, or immunodeficiency.

The spectrum of perianal Crohn's disease in a population-based cohort.

BACKGROUND: Perianal Crohn's disease represents a phenotype distinct from luminal Crohn's disease and may follow a different course. To date, the only detailed classifications of perianal Crohn's disease arise from referral center cohorts that do not reflect the spectrum of disease in the population as a whole. OBJECTIVES: The aim of this study was to document the rate, classification, and time course of symptomatic perianal Crohn's disease in a population-based cohort. DESIGN: This is a population-based cohort study. SETTING: : This study was conducted in the Canterbury region of New Zealand. PATIENTS: All patients with IBD in Canterbury, New Zealand, were eligible for recruitment over a 3-year period. MAIN OUTCOME MEASURES: The clinical records of all patients with Crohn's disease were reviewed, and all symptomatic perianal disease was classified according to the American Gastroenterological Society position statement. The rate of perianal involvement and timing of onset relative to Crohn's diagnosis was determined. RESULTS: Ninety-one percent of IBD patients in the region were recruited. Seven hundred fifteen patients had Crohn's disease, of which 190 (26.6%) patients had symptomatic perianal disease. The median age of patients with perianal disease was 37 years (range, 4-82 years) and 58.4% were female. Median follow-up was 9 years (range, 2 months to 45 years) from Crohn's disease diagnosis. Onset of perianal disease ranged from 18 years pre-Crohn's diagnosis to 33 years post-Crohn's diagnosis. Fistulas were the most common lesion (50% of patients), followed by perianal abscesses (42.1%), fissures (32.6%), skin tags (11.1%), strictures (7.4%), and hemorrhoids (1.6%). The cumulative probability at 20 years of any perianal Crohn's disease was 42.7% and of a perianal fistula 28.3%. LIMITATIONS: This study assumed all noted perianal lesions were related to Crohn's disease and the retrospective classification may have been inaccurate in some cases. CONCLUSIONS: This study provides the first detailed classification of perianal Crohn's disease in a population-based cohort.

German S3 guideline: anal abscess.

BACKGROUND: The incidence of anal abscess is relatively high, and the condition is most common in young men. METHODS: A systematic review of the literature was undertaken. RESULTS: This abscess usually originates in the proctodeal glands of the intersphincteric space. A distinction is made between subanodermal, intersphincteric, ischioanal, and supralevator abscesses. The patient history and clinical examination are diagnostically sufficient to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in recurrent abscesses or supralevator abscesses. The timing of the surgical intervention is primarily determined by the patient's symptoms, and acute abscess is generally an indication for emergency treatment. Anal abscesses are treated surgically. The type of access (transrectal or perianal) depends on the abscess location. The goal of surgery is thorough drainage of the focus of infection while preserving the sphincter muscles. The wound should be rinsed regularly (using tap water). The use of local antiseptics is associated with a risk of cytotoxicity. Antibiotic treatment is only necessary in exceptional cases. Intraoperative fistula exploration should be conducted with extreme care if at all; no requirement to detect fistula should be imposed. The risk of abscess recurrence or secondary fistula formation is low overall, but they can result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas and by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. CONCLUSION: In this clinical S3 guideline, instructions for diagnosis and treatment of anal abscess are described for the first time in Germany.

Nonfistulizing perianal Crohn's disease: clinical features, epidemiology, and treatment.

Nonfistulizing perianal lesions, including ulcerations, strictures, and anal carcinoma, are frequently observed in Crohn's disease. Their clinical course remains poorly known. The management of these lesions is difficult because none of the treatments used is evidence-based. Ulcerations may be symptomatic in up to 85% of patients. Most ulcerations heal spontaneously but may also progress to anal stenosis or fistula/abscess. Topical treatments only improve symptoms, while complete healing can occur in patients with perianal ulcerations receiving infliximab therapy. Half of all patients with anal strictures will require permanent fecal diversion. Dilatation for symptomatic strictures should be performed on a highly selective basis in the absence of active rectal disease in order to avoid infectious complications. Anorectal strictures associated with rectal lesions should first be managed with medical therapy. Skin tags are usually painless and may hide other perianal lesions. Anal cancer is uncommon. Its treatment is similar to that recommended for anal cancer occurring in non-Crohn's disease patients. After reviewing the classification, clinical features, and epidemiology of each type of nonfistulizing perianal lesion (ulceration, stricture, skin tags, and anal cancer), we discuss the efficacy of medical treatment and surgery. This review article may help physicians in decision-making when managing potentially disabling lesions.

Randomized, comparative efficacy trial of oral penicillin versus cefuroxime for perianal streptococcal dermatitis in children.

OBJECTIVE: To investigate the efficacy of penicillin compared with cefuroxime for group A beta-hemolytic Streptococcus pyogenes (GABHS) perianal dermatitis. STUDY DESIGN: Children 1 to 16 years of age with signs and symptoms of perianal dermatitis and a positive anal swab were randomized to penicillin or cefuroxime treatment and were clinically re-evaluated on day 3 and at the end of treatment (cefuroxime, day 7; penicillin, day 10). An anal swab was obtained to document eradication of GABHS at the end of treatment. Severity of disease was assessed with a clinical score (perianal erythema, 5 points; perianal itch, 3 points; painful defecation, 3 points; constipation, 2 points). RESULTS: Patients were enrolled and randomly assigned to penicillin (n = 18) or cefuroxime (n = 17) treatment. Treatment with penicillin was inferior to cefuroxime, which led to premature study termination after consultation with the ethics committee. Clinical improvement was more rapid in the cefuroxime group (P = .028) and GAHBS was not isolated from the anus the last day of therapy in 13 of 14 patients treated with cefuroxime compared with 7 of 15 patients treated with penicillin (P < .01). CONCLUSIONS: Cefuroxime was more effective than penicillin and therefore should be considered as the treatment of choice for perianal dermatitis due to GABHS.

Perianal Crohn's disease: classification and clinical evaluation.

Perianal manifestations are common in patients with Crohn's disease and include skin tags and haemorrhoids, fissures, ulcers, abscesses, fistulas, stenosis or cancer. Primary lesions include Crohn's fissures and cavitating perianal ulcers. Secondary lesions include deep abscesses, fistulas and strictures. A good classification and anatomical description of these conditions is crucial before embarking on any kind of (medical or surgical) therapy, as this greatly influences management. This review analyses and discusses current classifications of any perianal form of Crohn's disease.

Enfermedad de Crohn perianal / Perianal Crohn's disease

Antecedentes: El manejo de las manifestaciones perianales en la enfermedad de Crohn es dificultoso. Su frecuencia varia entre 6 y el 34 por ciento. El tratamiento conservador es lo sugerido. En la actualidad esto se ve favorecido por los nuevos tratamientos con drogas inmunosupresoras. Objetivo: Actualizar los conceptos básicos sobre el tratamiento médico y quirúrgico de la enfermedad de Chron perianal. Material y Método: Revisión bibliográfica a través de bases de datos MEDLINE, COCHRANE y PUBMED. Resultados: Se incluyen bajo la denominación de enfermedad de Crohn perianal aquellas manifestaciones perianales concomitantes con la enfermedad, o compatibles con dicho diagnóstico en ausencia de la misma. Su frecuencia varia según los criterios de inclusión utilizados. La clasificación anatómica de Cardiff y el índice de actividad de la enfermedad perianal de la Universidad de McMaster son las más apropiadas para el manejo de los pacientes. La estrategia diagnóstica debe enfocarse en evaluar la extensión y actividad de la enfermedad. Las modalidades más utilizadas son el examen bajo anestesia, la resonancia magnética y la ecografía endorrectal. El tratamiento debe ser siempre individualizado y, en general, lo más conservador posible. Conclusión: La enfermedad de Crohn perianal debe ser correctamente evaluada para su tratamiento. Los nuevos tratamientos con drogas inmunosupresoras han mejorado su evolución, permitiendo un manejo conservador con buenos resultados.