Abstract
Most patients with perianal Crohn's disease are asymptomatic and perianal disease may resolve given adequate medical treatment for the underlying intestinal lesion. This will consist principally of sulphasalazine and prednisolone, both of which are known to be effective in the treatment of Crohn's disease. Should the local perianal disease become more severe, a trial of oral metronidazole may be worthwhile. The development of an ischiorectal or perianal abscess is an indication for the simplest surgical drainage procedure, and rectal strictures resulting from the healing of perianal fissures may be gently dilated. Further progression of disease may be treated by diversion of the fecal stream, but this will stand a greater chance of success in patients without florid rectal Crohn's disease. Fecal diversion is also indicated as a preliminary to the repair of rectovaginal fistulas. Patients with florid perianal Crohn's disease and severe anorectal disease will probably come to proctocolectomy, but initial defunctioning of the colon will make the operative procedure easier, may facilitate perineal healing, and some patients may actually avoid proctectomy with its high risk of a persistent perineal sinus.
Résumé
Dans la majorité des cas la maladie de Crohn périanale est asymptomatique et répond favorablement à un traitement médical adéquat de la lésion intestinale initiale, traitement consistant essentiellement en l'emploi de la Salazopyrine et de la prédnisolone dont l'efficacité est reconnue. Les lésions deviendraient—elles plus intenses qu'un essai de traitement oral par le métronidazole peut Être couronné de succès. La constitution d'un abcès ischio-rectal ou périanal relève simplement d'une intervention de drainage alors que les sténoses rectales consécutives à la cicatrisation de fissures périanales peuvent Être traitées par dilatation douce. Si la maladie progresse il peut Être nécéssaire d'établir une dérivation intestinale, les chances de succès étant d'autant plus grandes que la maladie de Crohn n'est pas active. La dérivation intestinale constitue l'intervention préliminaire au traitement d'une fistule recto-vaginale. Lorsque la maladie de Crohn périanale est active et les lésions ano-rectales sont graves, il devient nécessaire de procéder à une proctocolectomie. Dans ce cas, la dérivation intestinale préalable rend l'intervention plus facile, la cicatrisation plus aisée et évite chez quelques malades la constitution d'une fistule permanente après la protectomie.
Resumen
La mayor parte de los pacientes con enfermedad de Crohn perianal permanecen asintomáticos y pueden exhibir resolución con el tratamiento médico adecuado de la enfermedad intestinal de base. Este consiste, principalmente, de Salazopirina y prednisolona, drogas de conocida efectividad en la terapia de la enfermedad de Crohn. En el caso de que la enfermedad perianal local se haga más severa, puede justificarse un ensayo con metronidazol oral. El desarrollo de un absceso isquiorrectal o perianal constituye indication para el procedimiento de drenaje quirÚrgico más simple que sea posible, y las estenosis rectales resultantes de la cicatrización de fisuras perianales pueden ser sometidas a dilatación delicada. La progresión de la enfermedad puede ser manejada mediante desviación del torrente fecal, pero existe mejor posibilidad de éxito en pacientes sin enfermedad rectal florida. La desviación fecal también está indicada como un procedimiento preliminar a la reparación de las fístulas rectovaginales. Los pacientes con enfermedad perianal florida y severa enfermedad anorrectal probablemente habrán de requerir proctocolectomía, pero la desfuncionalización inicial del colon facilita la operación, puede estimular la cicatrización perianal, y en algunos pacientes logra evitar la proctectomía con su alto riesgo de fístula perianal persistente.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Baker, W.N., Milton-Thompson, G.J.: The anal lesion as a sole presenting symptom of intestinal Crohn's disease. Gut12:A865, 1971
Heuman, R., Bolin, T., Sjodahl, R., Tagesson, C.: The incidence and cause of perianal complications and arthralgia after intestinal resection with restoration of continuity for Crohn's disease. Br. J. Surg.68:528, 1981
Homan, W.P., Tang, C.K., Thorbarnasson, B.: Anal lesions complicating Crohn's disease. Arch. Surg.11:1333, 1976
Rankin, G.B., Watt, D., Melyk, C.S.: National cooperative Crohn's disease study. Extraintestinal manifestations and perianal complications. Gastroenterology77:914, 1979
Lockhart-Mummery, H.E.: Crohn's disease: Anal lesions. Dis. Colon Rectum18:200, 1975
Loygue, J., Huguier, M.: Le traitement chirurgical des localisations ano-rectales de la maladie de Crohn. Arch. Fr. Mal. App. Dig.60:29, 1971
Keighley, M.R.B., Allan, R.N.: Current status and influence of operation on perianal Crohn's disease. Int. J. Colorectal. Dis. (in press)
Fielding, J.F.: Perianal lesions in Crohn's disease. J.R. Coll. Surg. Edinb.32:1717, 1972
Hughes, L.E., Jones, I.R.G.: Perianal lesions in Crohn's Disease. In Inflammatory Bowel Diseases, R.N. Allan, M.R.B. Keighley, C. Hawkins, J. Alexander-Williams, editors, Edinburgh, ChurchillLivingstone, 1982, pp. 321–331
Alexander-Williams, J., Buchmann, P.: Perianal Crohn's disease. World J. Surg.4:203, 1980
Buchmann, P., Keighley, M.R.B., Allan, R.N., Thompson, H., Alexander-Williams, J.: Natural history of perianal Crohn's disease. Ten year follow-up: A plea for conservatism. Am. J. Surg.140:642, 1980
Keighley, M.R.B., Allan, R.N.: Current status and influence of operation on perianal Crohn's disease. Int. J. Colorectal Dis.1:104, 1986
Lockhart-Mummery, H.E., Morson, B.C.: Crohn's disease of the large bowel. Gut5:493, 1964
Garlock, J.H.: Surgery of the Alimentary Tract, London, Butterworths, 1967
Hellers, G., Bergstrand, O., Ewerth, S.: Occurrence and outcome of the primary treatment of anal fistulae in Crohn's disease. Gut21:525, 1980
Summers, R.W., Switz, D.M., Sessions, J.T., Becktel, J.M., Best, W.R., Kern, F., Singleton, J.W.: National cooperative Crohn's disease study: Results of drug treatment. Gastroenterology77:847, 1979
Malchow, H., Ewe, K., Branders, J.W.: European cooperative Crohn's disease study (ECCDS). Results of drug treatment. Gastroenterology86:249, 1984
Brooke, B.N., Cave, D.R., King, D.W.: The place of azothiaprine for Crohn's disease. Lancet1:1041, 1976
Present, D.M., Korclitz, B.I., Wisch, N., Glass, J.L., Sachar, D.B., Pasternack, B.S.: Treatment of Crohn's disease with 6-mecaptopurine. N. Engl. J. Med.302:981, 1980
Allan, R.N., Cooke, T.W.: Evaluation of metronidazole in the management of Crohn's disease. Gut18:A422, 1977
Bernstein, L.H., Frank, M.S., Brandt, L.J.: Healing of perianal Crohn's disease with metronidazole. Gastroenterology79:357, 1982
Brandt, L.J., Bernstein, L.H., Bolye, J.S., Frank, M.S.: Metronidazole therapy for perianal Crohn's disease: A follow-up study.
Ambrose, N.S., Allan, R.N., Keighley, M.R.B., Burdon, D.W., Youngs, D., Barnes, P., Lennard-Jones, J.E.: Antibiotic therapy for treatment in relapsed intestinal Crohn's disease. Dis. Colon Rectum28:81, 1984
Ursing, B., Alm, T., Baramy, F.: A comparative study of metronizadole and sulfasalazine for active Crohn's disease. The cooperative Crohn's disease study in Sweden. II: Results. Gastroenterology83:550, 1984
Blichfeldt, P., Blomhoff, J.P., Myhre, E., Gjne, E.: Metronidazole in Crohn's disease: A double blind cross-over clinical trial. Scand. J. Gastroenterol.13:123, 1978
Gnarpe, H., Persson, S., Belsheim, J.: Influence of metronidazole and tinidazole on leucocyte chemotaxis in Crohn's disease. Infection6[Suppl.]: 107, 1978
Grove, D.I., Mahmoud, A.A.F., Warren, K.S.: Suppression of cell mediated immunity by metronidazole. Int. Arch. Allergy Appl. Immunol.54:422, 1977
Marks, C.G., Ritchie, J.K., Lockhart-Mummery, H.E.: Anal fistulas in Crohn's disease. Br. J. Surg.68:525, 1981
Parks, A.G.: Pathogenesis and treatment of fistula-in-ano. Br. Med. J.1:463, 1961
Sohn, N., Korclitz, B., Weinstein, M.A.: Anorectal Crohn's disease: Definitive surgery for fistulas and recurrent abscess. Am. J. Surg.139:394, 1980
Givel, J.C., Hawker, P., Allan, R.N., Alexander-Williams, J.: Enterovaginal fistulas associated with Crohn's disease. Surg. Gynecol. Obstet.155:494, 1982
Alexander-Williams, J., Allan, A., Morel, P.: Therapeutic co-axial balloon dilatation of Crohn's stricture. Ann. R. Coll. Surg. Engl.68:95, 1986
Lockhart-Mummery, H.E.: Perianal Crohn's disease. Invited commentary. World J. Surg.4:208, 1980
Jeffrey, P.J., Ritchie, J.K., Parks, A.G.: Treatment of haemorrhoids in patients with inflammatory bowel disease. Lancet1:1084, 1977
O'Morain, C., Segal, A.W., Levi, A.J.: Elemental diet as a primary treatment of acute Crohn's disease: A controlled trial. Br. Med. J.288:1859, 1984
Saverymutu, S., Hodgson, H.J.F., Chadwick, V.S.: Controlled trial comparing prednisolone with an elemental diet plus nonabsorbable antibiotics in active Crohn's disease. Gut26:994, 1985
Alexander-Williams, J.: Loop ileostomy and colostomy for faecal diversion. Ann. R. Coll. Surg. Engl.54:141, 1974
Lee, E.: Split ileostomy in the treatment of Crohn's disease of the colon. Ann. R. Coll. Surg. Engl.56:94, 1975
Harper, P.H., Kettlewell, M.G.W., Lee, E.: The effect of split ileostomy on perianal Crohn's disease. Br. J. Surg.69:608, 1982
Zelas, P., Jagelman, D.G.: Loop ileostomy in the management of Crohn's colitis in the debilitated patient. Ann. Surg.191:164, 1980
Harper, P.H., Truelove, S.C., Lee, E.C.G., Kettlewell, M.G.W., Jewell, D.P.: Split ileostomy and ileocolostomy for Crohn's disease of the colon and ulcerative colitis: A 20 year survey. Gut24:106, 1983
Scammell, B.E., Keighley, M.R.B.: Delayed perineal wound healing after proctectomy for Crohn's colitis. Br. J. Surg.73:150, 1986
Wetterman, L.T., Pena, A.S.: The place of split ileostomy in the management of Crohn's disease. In The Management of Crohn's Disease, Oxford, Excerpta Med. Amsterdam, 1976, p. 224
Oberhelman, H.A.: The effect of intestinal diversion by ileostomy on Crohn's disease of the colon. In The Management of Crohn's Disease, Oxford, Excerpta Med. Amsterdam, 1976, p. 216
Berman, J.H., Thompson, H., Cooke, W.T., Alexander-Williams, J.: The effect of diversion of intestinal contents on the progress of Crohn's disease of the large bowel. Gut12:11, 1971
McIlrath, D.C.: Diverting ileostomy or colostomy in the management of Crohn's disease of the colon. Arch. Surg.103:308, 1971
Alexander-Williams, J.: Perianal Crohn's Disease, Oxford, Excerpta Med. Amsterdam, 1975, p. 43
Buchmann, P., Allan, R.B., Thompson, H., Alexander-Williams, J.: Carcinoma developing in a recto-vaginal fistula in Crohn's disease. Am. J. Surg.140:462, 1980
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Allan, A., Keighley, M.R.B. Management of perianal Crohn's disease. World J. Surg. 12, 198–202 (1988). https://doi.org/10.1007/BF01658054
Issue Date:
DOI: https://doi.org/10.1007/BF01658054