1
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Li J, Ng WY, Qiao LC, Yuan F, Lan X, Zhu LB, Yang BL, Wang ZQ. Prevalence and risk factors of depression among patients with perianal fistulizing Crohn's disease. World J Psychiatry 2024; 14:715-725. [PMID: 38808090 PMCID: PMC11129156 DOI: 10.5498/wjp.v14.i5.715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Psychological distress, especially depression, associated with perianal fistulizing Crohn's disease (PFCD) is widespread and refractory. However, there is a surprising paucity of studies to date that have sought to identify the prevalence and risk factors of depression associated with PFCD. AIM To estimate the prevalence of depressive symptoms and investigate the depression-related risk factors in patients with PFCD. METHODS The study was conducted in the form of survey and clinical data collection via questionnaire and specialized medical staff. Depressive symptoms, life quality, and fatigue severity of patients with PFCD were assessed by Patient Health Questionnaire-9, Inflammatory Bowel Disease Patient Quality of Life Questionnaire (IBDQ), and Inflammatory Bowel Disease (IBD) Fatigue Patient Self-assessment Scale. The basic demographic information, overall disease features, perianal clinical information, and laboratory inflammation indicators were also gathered. Multivariate regression analysis was ultimately used to ascertain the risk factors of depression associated with PFCD. RESULTS A total of 123 patients with PFCD were involved, and 56.91% were suffering from depression. According to multivariate logistic regression analysis, Perianal Disease Activity Index (PDAI) score [odds ratio (OR) = 0.69, 95% confidence interval (CI): 0.50 to 0.95], IBDQ score (OR = 0.93, 95%CI: 0.88 to 0.97), modified Van Assche index (OR = 1.24, 95%CI: 1.01 to 1.53), and IBD Fatigue score (OR = 1.72, 95%CI: 1.23 to 2.42) were independent risk factors of depression-related prevalence among patients with PFCD (P < 0.05). Multiple linear regression analysis revealed that the increasing perianal modified Van Assche index (β value = 0.166, 95%CI: 0.02 to 0.31) and decreasing IBDQ score (β value = -0.116, 95%CI: -0.14 to -0.09) were independently associated with the severity of depression (P < 0.05). CONCLUSION Depressive symptoms in PFCD patients have significantly high prevalence. PDAI score, modified Van Assche index, quality of life, and fatigue severity were the main independent risk factors.
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Affiliation(s)
- Jing Li
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Wing-Yi Ng
- Department of Acupuncture and Rehabilitation, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Li-Chao Qiao
- Department of Colorectal Surgery, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Fen Yuan
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Xing Lan
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Li-Bei Zhu
- Department of Colorectal Surgery, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Bo-Lin Yang
- Department of Colorectal Surgery, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Zhong-Qiu Wang
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing 210029, Jiangsu Province, China
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2
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Devi J, Ballard DH, Aswani-Omprakash T, Parian AM, Deepak P. Perianal fistulizing Crohn's disease: Current perspectives on diagnosis, monitoring and management with a focus on emerging therapies. Indian J Gastroenterol 2024; 43:48-63. [PMID: 38308773 DOI: 10.1007/s12664-024-01524-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/02/2024] [Indexed: 02/05/2024]
Abstract
Crohn's disease (CD), a chronic inflammatory bowel disorder, manifests in various phenotypes, with fistulizing perianal CD (CD-PAF) being one of its most severe phenotypes. Characterized by fistula formation and abscesses, CD-PAF impacts 17% to 34% of all CD cases and with a significantly deleterious impact on patient's quality of life, while increasing the risk for anorectal cancers. The pathogenesis involves a complex interplay of genetic, immunological and environmental factors, with cytokines such as tumor necrosis factor-alpha (TNF-α) and transforming growth factor-beta (TGF-β) playing pivotal roles. Diagnostic protocols require a multi-disciplinary approach including colonoscopy, examination under anesthesia and magnetic resonance imaging. In terms of treatment, biologics alone often prove inadequate, making surgical interventions such as setons and fistula surgeries essential. Emerging therapies such as mesenchymal stem cells are under study. The South Asian context adds layers of complexity, including diagnostic ambiguities related to high tuberculosis prevalence, healthcare access limitations and cultural stigma toward perianal Crohn's disease and ostomy surgery. Effective management necessitates an integrated, multi-disciplinary approach, especially in resource-constrained settings. Despite advances, there remain significant gaps in understanding the disease's pathophysiology and a dearth of standardized outcome measures, underscoring the urgent need for comprehensive research.
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Affiliation(s)
- Jalpa Devi
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, Campus Box 8124, Saint Louis, MO, 63110, USA
| | - David H Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St. Louis, MO, USA
| | | | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Parakkal Deepak
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in Saint Louis, 660 S. Euclid Avenue, Campus Box 8124, Saint Louis, MO, 63110, USA.
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3
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Alves Martins BA, Filho ODM, Lopes ACB, de Faria RJ, Silva C, Lemos GDO, Silveira DB, de Sousa JB. Nutritional status in perianal Crohn's disease: are we underestimating the impact? Front Nutr 2023; 10:1271825. [PMID: 37743921 PMCID: PMC10512412 DOI: 10.3389/fnut.2023.1271825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Symptomatic perianal disease is common in patients with Crohn's disease (CD), and perianal fistulas represent the primary form of anal involvement. This type of involvement is associated with a poor prognosis and a disabling course. The treatment is challenging and involves both surgical and medical approaches. Despite combined therapy, a significant portion of patients may still require proctectomy to control the symptoms. Consequently, investigating factors that may influence the outcome of perianal disease remains a priority area of research in CD. Nutritional deficiencies are well documented among CD patients with luminal forms of involvement and are closely related to poor clinical outcomes, therapy response, and postoperative complications. As a result, leading guidelines recommend regular nutritional assessment and correction of nutritional deficiencies in patients requiring a surgical approach. Despite these recommendations and the high rate of surgeries among CD patients with perianal disease, there is a shortage of studies addressing the real impact of nutritional status on the course and outcomes of perianal disease. This knowledge gap underscores the importance of further research to understand better and improve the management of perianal CD. This narrative review aims to provide an overview of nutritional status assessment and the influence of nutritional status on the outcomes of patients with perianal CD.
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Affiliation(s)
- Bruno Augusto Alves Martins
- Medical Sciences Postgraduate Program, School of Medicine, University of Brasilia, Brasília, Brazil
- Department of Colorectal Surgery, Hospital Universitário de Brasília, Brasília, Brazil
| | - Oswaldo de Moraes Filho
- Medical Sciences Postgraduate Program, School of Medicine, University of Brasilia, Brasília, Brazil
- Department of Colorectal Surgery, Hospital Universitário de Brasília, Brasília, Brazil
| | | | | | - Clíslian Silva
- Department of Nutrition and Dietetics, Hospital Universitário de Brasília, Brasília, Brazil
| | | | | | - João Batista de Sousa
- Medical Sciences Postgraduate Program, School of Medicine, University of Brasilia, Brasília, Brazil
- Department of Colorectal Surgery, Hospital Universitário de Brasília, Brasília, Brazil
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4
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Parian AM, Obi M, Fleshner P, Schwartz DA. Management of Perianal Crohn's Disease. Am J Gastroenterol 2023; 118:1323-1331. [PMID: 37207318 DOI: 10.14309/ajg.0000000000002326] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 05/21/2023]
Abstract
Perianal Crohn's disease affects 25%-35% of patients with Crohn's disease and has proven to be one of the most difficult complications of the disease to treat. Patients with perianal Crohn's disease have lower health-related quality of life scores typically related to pain and fecal incontinence. In addition, patients with perianal Crohn's disease have higher rates of hospitalizations, surgeries, and overall healthcare costs. A multidisciplinary approach is necessary for the successful management of Crohn's disease with perianal fistula. Medical management is required to treat the underlying immune dysregulation to heal the luminal inflammation and the inflammation within the fistula tracts. Current options for medical therapy include biologics, dual therapy with thiopurines, therapeutic drug monitoring, and a close follow-up. Surgical management is critical to drain abscesses before immunosuppressive therapy and place setons when appropriate. Once the patient's inflammatory burden is well managed, definitive surgical therapies including fistulotomies, advancement flaps, and ligation of intersphincteric fistula tract procedures can be considered. Most recently, the use of stem cell therapy in the treatment of perianal fistula has given new hope to the cure of perianal fistula in Crohn's disease. This review will outline the most current data in the medical and surgical management of perianal Crohn's disease.
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Affiliation(s)
- Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Megan Obi
- Department of General Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - David A Schwartz
- Inflammatory Bowel Disease Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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5
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Bellou O, Chrysikos D, Schoinohoriti O, Alexandrou I, Christianakis E. Perianal Skin Tags Revealing Asymptomatic Crohn's Disease in a 12-Year-Old Child With Growth Impairment: A Case Report. Cureus 2023; 15:e37513. [PMID: 37193423 PMCID: PMC10182382 DOI: 10.7759/cureus.37513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2023] [Indexed: 05/18/2023] Open
Abstract
Pediatric Crohn's disease (CD) is a chronic inflammatory bowel disease considered to impair the growth of children and adolescents. Since CD commonly presents perianal manifestations, general surgeons may play a crucial role in its diagnosis and treatment. Detailed history, along with a thorough clinical examination, is mandatory for the management of CD perianal lesions. However, surgical intervention is only indicated in selected patients since it may lead to poor wound healing and recurrence. The article reports a case of a 12-year-old girl, presenting perianal skin tags and growth impairment as the first signs of asymptomatic CD.
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Affiliation(s)
- Olga Bellou
- 2nd Department of General Surgery, KAT General Hospital of Athens, Athens, GRC
| | | | - Ourania Schoinohoriti
- Department of Oral and Maxillofacial Surgery, School of Dentistry, University of Athens, Athens, GRC
| | - Ioannis Alexandrou
- Department of Pediatric Surgery, General Children Hospital of Penteli, Athens, GRC
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6
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Di Candido F. Quality of Life in Inflammatory Bowel Diseases (IBDs) Patients after Surgery. Rev Recent Clin Trials 2022; 17:227-239. [PMID: 35959618 DOI: 10.2174/1574887117666220811143426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 04/09/2022] [Accepted: 05/11/2022] [Indexed: 01/15/2023]
Abstract
Inflammatory Bowel Diseases (IBDs) are chronic, relapsing and disabling diseases that affect the gastrointestinal tract. This relapsing course is often unpredictable with severe flares and the need for intensive medical treatment, hospitalization, or emergent/urgent surgery, all of which significantly impact patients' quality of life (QoL). QoL in IBD patients is significantly lower than in the general population, and depression and anxiety have been shown to have a higher prevalence than in healthy individuals, especially during disease flares. Complications requiring hospitalization and repeated surgeries are not uncommon during the disease course and significantly affect QoL in IBD patients. Patient-reported outcome measures (PROMs) can be used to measure the impact of chronic disease on QoL from the patient's perspective. The use of PROMs in IBD patients undergoing surgery could help to investigate the impact of the surgical procedure on QoL and determine whether there is any improvement or worsening. This review summarizes the use of PROMs to assess QoL after various surgical procedures required for IBD treatment.
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Affiliation(s)
- Francesca Di Candido
- Division of General and Emergency Surgery, ASST Nord Milano, Sesto San Giovanni Hospital, Viale Matteotti, 83 - 20099 Sesto San Giovanni (MI) - Italy
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7
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Pagani K, Lukac D, Bhukhan A, McGee JS. Cutaneous Manifestations of Inflammatory Bowel Disease: A Basic Overview. Am J Clin Dermatol 2022; 23:481-497. [PMID: 35441942 DOI: 10.1007/s40257-022-00689-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2022] [Indexed: 11/30/2022]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal (GI) tract that is subdivided into Crohn's disease (CD) and ulcerative colitis (UC). CD is characterized by involvement of the entire GI tract, while UC mainly affects the distal GI tract. Moreover, both CD and UC can present with extraintestinal manifestations (EIMs) of the disease affecting multiple organ systems including the hepatobiliary tract, kidney, bones, eyes, joints, and skin. These complications can cause significant morbidity and negatively impact the quality of life for IBD patients. Although the pathogenesis of EIMs is not clearly elucidated, it is postulated that the diseased GI mucosa similarly stimulates excess immune responses at the extraintestinal sites. Cutaneous EIMs occur in up to 15% of patients with IBD, often predating their IBD diagnosis. They are categorized into (1) specific, (2) reactive, (3) associated, and (4) treatment-induced. Here, we review the epidemiological, clinical, diagnostic, and histologic features of the most commonly described cutaneous EIMs of IBD along with their respective treatment options.
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Affiliation(s)
- Kyla Pagani
- Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Danitza Lukac
- Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Aashni Bhukhan
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Ft. Lauderdale, FL, USA
| | - Jean S McGee
- Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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8
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Grossi U, Gallo G, Di Tanna GL, Bracale U, Ballo M, Galasso E, Kazemi Nava A, Zucchella M, Cinetto F, Rattazzi M, Felice C, Zanus G. Surgical Management of Hemorrhoidal Disease in Inflammatory Bowel Disease: A Systematic Review with Proportional Meta-Analysis. J Clin Med 2022; 11:709. [PMID: 35160159 PMCID: PMC8837177 DOI: 10.3390/jcm11030709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 02/06/2023] Open
Abstract
Surgical treatment of hemorrhoidal disease (HD) in inflammatory bowel disease (IBD) has been considered to be potentially harmful, but the evidence for this is poor. Therefore, a systematic review of the literature was undertaken to reappraise the safety and effectiveness of surgical treatments in this special circumstance. A MEDLINE, Web of Science, Scopus, and Cochrane Library search was performed to retrieve studies reporting the outcomes of surgical treatment of HD in patients with Crohn's disease (CD) and ulcerative colitis (UC). From a total of 2072 citations, 10 retrospective studies including 222 (range, 2-70) patients were identified. Of these, 119 (54%) had CD and 103 (46%) UC. Mean age was between 41 and 49 years (range 14-77). Most studies lacked information on the interval between surgery and the onset of complications. Operative treatments included open or closed hemorrhoidectomy (n = 156 patients (70%)), rubber band ligation (n = 39 (18%)), excision or incision of thrombosed hemorrhoid (n = 14 (6%)), and doppler-guided hemorrhoidal artery ligation (DG-HAL, n = 13 (6%)). In total, 23 patients developed a complication (pooled prevalence, 9%; (95%CI, 3-16%)), with a more than two-fold higher rate in patients with CD compared to UC (11% (5-16%) vs. 5% (0-13%), respectively). Despite the low quality evidence, surgical management of HD in IBD and particularly in CD patients who have failed nonoperative therapy should still be performed with caution and limited to inactive disease. Further studies should determine whether advantages in terms of safety and effectiveness with the use of non-excisional techniques (e.g., DG-HAL) can be obtained in this patient population.
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Affiliation(s)
- Ugo Grossi
- II Surgery Unit, Regional Hospital Treviso, AULSS2, 31100 Treviso, Italy; (M.B.); (E.G.); (A.K.N.); (M.Z.); (G.Z.)
- Department of Surgery, Oncology and Gastroenterology-DISCOG, University of Padua, 35128 Padua, Italy
| | - Gaetano Gallo
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, University of Siena, 53100 Siena, Italy;
| | - Gian Luca Di Tanna
- Statistics Division, The George Institute for Global Health, University of New South Wales, Sydney 2042, Australia;
| | - Umberto Bracale
- Department of Advanced Biomedical Sciences, ‘Federico II’ University of Naples, 80131 Naples, Italy;
| | - Mattia Ballo
- II Surgery Unit, Regional Hospital Treviso, AULSS2, 31100 Treviso, Italy; (M.B.); (E.G.); (A.K.N.); (M.Z.); (G.Z.)
- Department of Surgery, Oncology and Gastroenterology-DISCOG, University of Padua, 35128 Padua, Italy
| | - Elisa Galasso
- II Surgery Unit, Regional Hospital Treviso, AULSS2, 31100 Treviso, Italy; (M.B.); (E.G.); (A.K.N.); (M.Z.); (G.Z.)
- Department of Surgery, Oncology and Gastroenterology-DISCOG, University of Padua, 35128 Padua, Italy
| | - Andrea Kazemi Nava
- II Surgery Unit, Regional Hospital Treviso, AULSS2, 31100 Treviso, Italy; (M.B.); (E.G.); (A.K.N.); (M.Z.); (G.Z.)
| | - Martino Zucchella
- II Surgery Unit, Regional Hospital Treviso, AULSS2, 31100 Treviso, Italy; (M.B.); (E.G.); (A.K.N.); (M.Z.); (G.Z.)
| | - Francesco Cinetto
- Department of Medicine-DIMED, University of Padua, 35128 Padua, Italy; (F.C.); (M.R.); (C.F.)
| | - Marcello Rattazzi
- Department of Medicine-DIMED, University of Padua, 35128 Padua, Italy; (F.C.); (M.R.); (C.F.)
| | - Carla Felice
- Department of Medicine-DIMED, University of Padua, 35128 Padua, Italy; (F.C.); (M.R.); (C.F.)
| | - Giacomo Zanus
- II Surgery Unit, Regional Hospital Treviso, AULSS2, 31100 Treviso, Italy; (M.B.); (E.G.); (A.K.N.); (M.Z.); (G.Z.)
- Department of Surgery, Oncology and Gastroenterology-DISCOG, University of Padua, 35128 Padua, Italy
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9
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Nazari H, Naei VY, Tabasi AH, Badripour A, Akbari Asbagh R, Keramati MR, Sharifi A, Behboudi B, Kazemeini A, Abbasi M, Keshvari A, Ahmadi Tafti SM. Advanced Regenerative Medicine Strategies for Treatment of Perianal Fistula in Crohn's Disease. Inflamm Bowel Dis 2022; 28:133-142. [PMID: 34291798 DOI: 10.1093/ibd/izab151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Indexed: 12/15/2022]
Abstract
Regenerative medicine is an emerging therapeutic method that aims to reconstruct tissues and organs. This advanced therapeutic approach has demonstrated great potential in addressing the limitations of medical and surgical procedures for treating perineal fistula in patients with Crohn's disease. Recent developments in stem cell technology have led to a massive good manufacturing practices (GMPs) production of various stem cells, including mesenchymal and embryonic cells, along with induction of pluripotent stem cells to repair damaged tissues in the fistula. The recent advances in separation and purification of exosomes, as biologic nanovesicles carrying anti-inflammatory and regenerative agents, have made them powerful tools to treat this inflammatory disease. Further, tremendous advances in nanotechnology, biomaterials, and scaffold fabrication methods enable tissue engineering methods to synthesize tissue-like structures to assist surgical techniques. This review focuses on advanced regenerative-based methods including stem cell therapy, exosome therapy, and tissue engineering used in the treatment of perianal fistula. Relevant in vitro and in vivo studies and the latest innovations in implementation of regenerative medicine for this disease are also separately reviewed. Additionally, current challenges regarding implementation of g stem cells, exosomes, and tissue engineering methods for bridging the gaps between laboratory findings and clinic application will be discussed.
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Affiliation(s)
- Hojjatollah Nazari
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Advanced Technologies in Cardiovascular Medicine, Tehran Heart Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Vahid Yaghoubi Naei
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Asieh Heirani Tabasi
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.,Department of Cell Therapy and Hematology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Abolfazl Badripour
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Akbari Asbagh
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Keramati
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirsina Sharifi
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Behboudi
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Kazemeini
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Amir Keshvari
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Ahmadi Tafti
- Division of Colorectal Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.,Colorectal Surgery Research Center, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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10
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Crippa J, Spinelli A. Evolving management strategies for perianal Crohn's fistulizing disease. Br J Surg 2021; 109:147-149. [PMID: 34849587 DOI: 10.1093/bjs/znab398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/14/2021] [Indexed: 11/13/2022]
Abstract
This is a review of perianal Crohn's disease providing insights into diagnostic, medical, and surgical pathways.
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Affiliation(s)
- Jacopo Crippa
- Division of Colon & Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Division of Colon & Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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11
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Ali AS, Alhothali OS, Hammoudah AA, Kh Alsaede A, Alraddadi AA. Multidrug Resistance and Flaring up of Manifestation in Fistulizing Crohn's Disease after Surgery on a Perianal Lesion. Case Rep Gastroenterol 2021; 15:626-631. [PMID: 34616267 PMCID: PMC8454242 DOI: 10.1159/000515611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 01/21/2023] Open
Abstract
Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract with relapsing and remitting episodes. Abscesses and fistulas are the most common presentations of anorectal Crohn's disease. Antibiotics and surgical incision and drainage have been successful in treating perianal disease. We present here a 48-year-old woman with known case of Crohn's disease who presented with massive swelling in the perianal region with severe throbbing pain and high-grade fever, 38.2°C; the surgeon noted a large perianal abscess near the anal verge with redness, hotness, and tenderness. One and a half months from perianal abscess surgery, culture sensitivity was done due to delayed wound healing and passage of greenish discharge, and it revealed highly resistant bacteria Proteus mirabilis, Escherichia coli, and Staphylococci. In conclusion, clinicians should be aware that abscess and fistula have a fair chance to develop in Crohn's disease patients who are using immunomodulating and immunosuppressant therapy. In abscess and fistula cases, surgery should be determined as soon as possible, and close clinical monitoring should be performed. We recommend routine screening for enteric fistula and culture sensitivity of any discharge prior to the initiation of any antibiotic. Appropriate intervention should then be undertaken.
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Affiliation(s)
- Abeer S Ali
- Pathology Department, Faculty of Medicine, Umm Al-Qurra University, Mecca, Saudi Arabia
| | - Omar S Alhothali
- Fifth year medical student, Umm Al-Qurra University, Mecca, Saudi Arabia
| | | | | | - Ayman A Alraddadi
- Fifth year medical student, Umm Al-Qurra University, Mecca, Saudi Arabia
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12
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De Simone B, Davies J, Chouillard E, Di Saverio S, Hoentjen F, Tarasconi A, Sartelli M, Biffl WL, Ansaloni L, Coccolini F, Chiarugi M, De’Angelis N, Moore EE, Kluger Y, Abu-Zidan F, Sakakushev B, Coimbra R, Celentano V, Wani I, Pintar T, Sganga G, Di Carlo I, Tartaglia D, Pikoulis M, Cardi M, De Moya MA, Leppaniemi A, Kirkpatrick A, Agnoletti V, Poggioli G, Carcoforo P, Baiocchi GL, Catena F. WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg 2021; 16:23. [PMID: 33971899 PMCID: PMC8111988 DOI: 10.1186/s13017-021-00362-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons. METHOD A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019. CONCLUSIONS Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.
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Affiliation(s)
- Belinda De Simone
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Justin Davies
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elie Chouillard
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy
| | - Frank Hoentjen
- RIMLS - Radboud Institute for Molecular Life Sciences, Radboud University-Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Antonio Tarasconi
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Walter L. Biffl
- Scripps Memorial Hospital La Jolla, San Diego, California USA
| | - Luca Ansaloni
- Department of Surgery, University Hospital of Pavia, Pavia, Italy
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Massimo Chiarugi
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Nicola De’Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Acquaviva delle Fonti (Bari), Italy
| | - Ernest E. Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital St George, Plovdiv, Bulgaria
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA USA
| | - Valerio Celentano
- Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Hampshire, UK
| | - Imtiaz Wani
- Government Gousia Hospital-Srinagar, Directorate of Health Services-Kashmir, Srinagar, Kashmir India
| | - Tadeja Pintar
- Department of Abdominal Surgery, Umc Ljubljana, Ljubljana, Slovenia
| | - Gabriele Sganga
- Department of Emergency Surgery, “A. Gemelli Hospital”, Catholic University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, General Surgery, Cannizzaro Hospital, Catania, Italy
| | - Dario Tartaglia
- Emergency Surgery Unit & Trauma Center, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Manos Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National & Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Maurizio Cardi
- Department of Oncological Surgery “P.Valdoni”, Sapienza University, Rome, Italy
| | - Marc A. De Moya
- Trauma/Acute Care Surgery Department, Medical College of Wisconsin/Froedtert Trauma Center, Wauwatosa, Wisconsin USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Gilberto Poggioli
- Department of Surgical Sciences, Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Paolo Carcoforo
- Department of Surgery, University Hospital of Ferrara, Ferrara, Italy
| | | | - Fausto Catena
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
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Lin SN, Zheng DP, Qiu Y, Zhang SH, He Y, Chen BL, Zeng ZR, Mao R, Chen MH. Classifying Crohn's disease into colon-involving versus non-colon-involving groups is a better predictor of clinical outcomes than the Montreal classification. Therap Adv Gastroenterol 2020; 13:1756284820968732. [PMID: 33329758 PMCID: PMC7720347 DOI: 10.1177/1756284820968732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/01/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A suitable disease classification is essential for individualized therapy in patients with Crohn's disease (CD). Although a potential mechanistic classification of colon-involving and non-colon-involving disease was suggested by recent genetic and microbiota studies, the clinical implication has seldom been investigated. We aimed to explore the association of this colonic-based classification with clinical outcomes in patients with CD compared with the Montreal classification. METHODS This was a retrospective study of CD patients from a tertiary referral center. Patients were categorized into colon-involving and non-colon-involving disease, and according to the Montreal classification. Clinico-demographic data, medications, and surgeries were compared between the two classifications. The primary outcome was the need for major abdominal surgery. RESULTS Of 934 patients, those with colonic involvement had an earlier median (interquartile range) age of onset [23.0 (17.0-30.0) versus 26.0 (19.0-35.0) years, p = 0.001], higher frequency of perianal lesions (31.2% versus 14.5%, p < 0.001) and extraintestinal manifestations (21.8% versus 14.5%, p = 0.010), but lower frequency of stricture (B2) (16.3% versus 24.0%, p = 0.005), than those with non-colon-involving disease. Colon-involving disease was a protective factor against major abdominal surgery [hazard ratio, 0.689; 95% confidence interval (CI), 0.481-0.985; p = 0.041]. However, patients with colon-involving CD were more prone to steroids [odds ratio (OR), 1.793; 95% CI, 1.206-2.666; p = 0.004] and azathioprine/6-mercaptopurine (AZA/6-MP) treatment (OR, 1.732; 95% CI, 1.103-2.719; p = 0.017) than were patients with non-colon-involving disease. The Montreal classification was not predictive of surgery or steroids and AZA/6-MP treatment. CONCLUSION This study supports the rationale for disease classification based on the involvement of colon. This new classification of CD is a better predictor of clinical outcomes than the Montreal classification.
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Affiliation(s)
- Si-Nan Lin
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Dan-Ping Zheng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Sheng-Hong Zhang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Bai-Li Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Zhi-Rong Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, Guangdong, P.R. China
| | - Min-Hu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, P.R. China
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Xu M, Yang B, Chen H, Gu Y, Li Y. Analysis of Risk Factors for Anorectal Stenosis of Perianal Fistulizing Crohn's Disease. Med Sci Monit 2020; 26:e920243. [PMID: 32109226 PMCID: PMC7063846 DOI: 10.12659/msm.920243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background To analyze the risk factors of anorectal stenosis associated with perianal fistulizing Crohn’s disease (PFCD). Material/Methods We retrospectively analyzed 139 cases of PFCD from January 2010 to December 2017 at the Affiliated Hospital of Nanjing University of Chinese Medicine. They were divided into 2 groups according to whether anorectal stenosis occurred. The possible factors associated with anorectal stenosis of PFCD were selected based on the literature review and clinical observations. Univariate analysis was performed to screen the risk factors of anorectal stenosis, and multivariate logistic regression analysis was performed on these risk factors and factors that were clinically considered to be potentially influential, to screen out the independent risk factors of anorectal stenosis. Results We found that 44 cases (31.7%) of PFCD were associated with anorectal stenosis. Univariate analysis showed that CDAI, lesion location, and age at diagnosis were risk factors for anorectal stenosis of PFCD. Logistic regression analysis showed that mild (fair to good) (OR=3.833, 95% CI: 1.123~13.080) to moderate (poor) (OR=7.345, 95% CI: 1.964~27.474) CDAI and age at diagnosis (OR=1.067, 95% CI: 1.013~1.124) were independent risk factors for anorectal stenosis of PFCD. Conclusions Higher CDAI and older age at diagnosis appear to confer higher risk of anorectal stenosis associated with PFCD.
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Affiliation(s)
- MinMin Xu
- Department of Colorectal Surgery of Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, China (mainland)
| | - BoLin Yang
- Department of Colorectal Surgery of Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, China (mainland)
| | - HongJin Chen
- The First Clinical Medical College of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China (mainland)
| | - YunFei Gu
- The First Clinical Medical College of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China (mainland)
| | - YouRan Li
- Department of Colorectal Surgery of Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, Jiangsu, China (mainland)
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Predictors of long-term outcomes of radiologically defined perianal fistulizing Crohn's disease treated with antitumor necrosis factor-alpha agents based on Parks' classification. Eur J Gastroenterol Hepatol 2020; 32:187-192. [PMID: 31851087 DOI: 10.1097/meg.0000000000001634] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Perianal fistulizing Crohn's disease (PFCD) leads to significant disability. Data assessing healing of complex PFCD based on pelvic MRI using Parks' classification remains sparse. We aimed to assess the frequency of closure of fistula tract on MRI in patients treated with antitumor necrosis factor alpha antagonists and identify predictors of poor response. MATERIALS AND METHODS We retrospectively identified patients registered in the Saudi Inflammatory Bowel Disease Information System registry, who were diagnosed as PFCD based on MRI and treated with infliximab or adalimumab. Fistulae were classified based on Parks' classification and response to treatment was determined as full, partial, or no response, after at least 12 months of treatment. RESULTS Out of 960 patients, 61 had complex PFCD that required treatment with an anti-TNF agent. The median age was 27 years (range: 14-69 years) and the median duration of disease was 6.2 ± 5.8 years. A full response to treatment was achieved in 27 (44.4%), whereas 10 patients (16.3%) had partial response and 24 (39.3%) had no response. On univariable analysis, a statistically significant association was observed between poor fistula response and low BMI, rectal involvement, fistulae classification, and the presence of an abscess. According to multivariable regression, only low BMI predicted poor fistulae outcome (odds ratio = 1.37, 95% confidence interval: 0.69-0.98). CONCLUSION Less than half of this cohort of patients with PFCD achieved complete radiological fistula healing with anti-TNF therapy. Low BMI appears to be the only predictor of poor outcome.
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16
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Keyashian K, Dehghan M, Sceats L, Kin C, Limketkai BN, Park KT. Comparative Incidence of Inflammatory Bowel Disease in Different Age Groups in the United States. Inflamm Bowel Dis 2019; 25:1983-1989. [PMID: 31095681 PMCID: PMC7534454 DOI: 10.1093/ibd/izz092] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data on the incidence of inflammatory bowel disease (IBD) by age group are available in countries outside of the United States or localized populations within the United States. We aimed to estimate the incidence rates (IRs) of IBD by age group using a US multiregional data set. METHODS We used the Optum Research Database to identify incident IBD patients with a disease-free interval of 1.5 years between 2005 and 2015. Overall and age-specific IRs were calculated for 4 different age groups: pediatric (0-17 years), young adult (18-25 years), adult (26-59 years), elderly (>60 years). Time trends of incidence were evaluated in each age group. Perianal phenotype (in Crohn's disease [CD]) was also compared. RESULTS The mean IR for the cohort (n = 60,247) from 2005 to 2015 was 37.5/100,000. The IR was highest in adult and elderly cohorts (36.4 and 36.7/100,000 respectively). In the adult and elderly groups, the IR for UC was higher than that for CD, whereas the opposite was true in the pediatric and young adult groups. The IR increased over the 10-year study period for all age groups (time trends P < 0.001). The elderly group had less perianal disease than the adult group (20.8 vs 22.3%, respectively; P < 0.05). CONCLUSIONS In one of the most comprehensive evaluations of the incidence of IBD in the United States, we found an incidence rate similar to those of other national populations. We also confirmed differences of specific IBD phenotypes based on age groups, with lower rates of perianal disease in the elderly.
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Affiliation(s)
- Kian Keyashian
- Division of Gastroenterology, Department of Medicine, Stanford, California, USA
- Address correspondence to: Kian Keyashian, MD, Stanford Health Care, 430 Broadway, Pavilion C—3rd Floor, Redwood City, CA 94063 ()
| | - Melody Dehghan
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California, USA
| | - Lindsay Sceats
- Department of Surgery & Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, Stanford, California, USA
| | - Cindy Kin
- Department of Surgery & Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University School of Medicine, Stanford, California, USA
| | | | - K T Park
- Stanford Children’s Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Pediatrics, Stanford, California, USA
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Gallo G, Sammarco G. Functional Assessment on IBD Patients: Is It A Must or Is It A Dust? J INVEST SURG 2019; 34:554-555. [PMID: 31661329 DOI: 10.1080/08941939.2019.1679294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Giuseppe Sammarco
- Department of Health Sciences, University of Catanzaro, Catanzaro, Italy
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Abstract
Medical treatment remains the mainstay of perianal disease management for CD; however, aggressive surgical management should be considered for severe or recurrent disease. In all cases of perianal CD, medical and surgical treatments should be used in tandem by a multidisciplinary team. Significant development has been made in the treatment of Crohn's-related fistulas, particularly minimally invasive options with recent clinical trials showing success with mesenchymal stem cell applications. Inevitably, some patients with severe refractory disease may require fecal diversion or proctectomy. When considering reversal of a diverting or end ileostomy, cessation of proctitis is the most important factor.
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Affiliation(s)
- Adam Truong
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA.
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Abstract
This article provides an overview of the principles in the evaluation and management of perianal Crohn's disease (CD). Manifestation-specific treatment is addressed including abscess, fistula, skin tags, hemorrhoids, fissure, ulcers, strictures, ano-, and rectovaginal fistulas as well CD-associated hidradenitis suppurativa.
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Affiliation(s)
| | - Gervasio Salgado
- Division of Colorectal Surgery, Hospital Santa Helena Los Álamos, Málaga, Spain
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20
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Seyedian SS, Nokhostin F, Malamir MD. A review of the diagnosis, prevention, and treatment methods of inflammatory bowel disease. J Med Life 2019; 12:113-122. [PMID: 31406511 PMCID: PMC6685307 DOI: 10.25122/jml-2018-0075] [Citation(s) in RCA: 283] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/27/2019] [Indexed: 12/11/2022] Open
Abstract
Ulcerative colitis (UC) and Crohn's disease (CD) are classified as chronic inflammatory bowel diseases (IBD) which have similar symptoms and lead to digestive disorders and inflammation in the digestive system. The reason why they occur is still a mystery. A number of factors can be attributed to the prevalence of CD and UC, some of which include geographical location, inappropriate diet, genetics, and inappropriate immune response. Both diseases are more often diagnosed in urban areas compared to rural areas and both have their own challenges and side effects, but the patients can still have a good quality of life. Given the fact that the prevalence of this disease is higher at younger ages and that it disrupts half the life of the patient, it will, most likely, become a major health problem in the near future, even in developing countries. By reviewing valid scientific resources and evaluating new methods of addressing this disease, the present study aims to provide researchers and patients with new insights into this field and facilitate access to new treatments.
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Affiliation(s)
- Seyed Saeid Seyedian
- Alimentary Tract Research Center, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran
| | - Forogh Nokhostin
- Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mehrdad Dargahi Malamir
- Faculty of Medicine, Medical doctor of Internal Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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21
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Ambulatory Surgery for Perianal Crohn's Disease: Study of Feasibility. Gastroenterol Res Pract 2018; 2018:5249087. [PMID: 30671093 PMCID: PMC6323458 DOI: 10.1155/2018/5249087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/01/2018] [Accepted: 12/03/2018] [Indexed: 12/15/2022] Open
Abstract
Background One-third of Crohn's disease (CD) patients present perianal fistula. The gold standard in the diagnosis and treatment of symptomatic perianal disease (PAD) in CD is the exploration of the anal canal and distal rectum under anesthesia (EUA). This procedure is mainly conducted as a day case surgery. Unfortunately, it is not always possible to proceed within the ideal timing and any delay may well represent a relevant clinical issue. The aim of this study was to evaluate the feasibility of outpatient treatment of symptomatic perianal fistulas in CD patients. Methods All CD patients under regular follow-up at our inflammatory bowel disease referral center, presenting with symptomatic perianal fistulas, were offered surgical consultation. The data of patients were prospectively collected for three years (February 2014 to February 2017) for the purpose of the study. All clinical information, including previous EUA and/or records from MRI and endoscopic ultrasound, was included. Outpatient anal canal and distal rectum exploration and treatment (OE) were undertaken during the specialist surgical consultation. Fistulas were classified according to Parks's classification; the type of outpatient treatment and compliance of patients were recorded. Pain was assessed by VAS at the time of the procedure and during the first control. Patients were followed up in the surgical clinic in relation to the study. Results Ninety-two CD patients with symptomatic perianal fistulas had surgical consultation during the study period. OE was offered to all but 18 patients who fulfilled the exclusion criteria or had an extremely severe disease; six patients refused the OE (8.11%). Of the 68 patients undergoing OE, eleven (16.18%) had previous surgery for perianal disease. The OE was accomplished in sixty-one patients (89.71%), while in 7 patients, it was abandoned for scarce compliance. Nine patients (14.75%) underwent drainage of perianal abscess; in 3 of them, it was possible to probe the fistula tract, find the internal orifice, and pass a loose seton. Overall, setonage was performed in 50 patients (81.97%). Rectovaginal setons were placed in 3 patients and more than one seton (up to 3) in 6 cases. Fistulotomy was performed in 4 simple subcutaneous fistulous tracts. Concordance with the preoperative findings was found in 54 out of 61 patients. EUA was scheduled at the time of OE for the 7 patients who did not complete the procedure. All sixty-one patients who had the OE were followed up for a minimum of 12 months. Conclusions This preliminary study indicates that OE in CD patients with symptomatic perianal fistulas is safe and feasible in a high-volume referral center. It might provide several benefits, including patients' logistics, reduce or remove patients' symptoms and discomfort, allow for a timely start of medical therapy, and avoid further complications.
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22
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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Mak WY, Mak OS, Lee CK, Tang W, Leung WK, Wong MTL, Sze ASF, Li M, Leung CM, Lo FH, Lam BCY, Chan KH, Shan EHS, Tsang SWC, Hui AJ, Chow WH, Chan FKL, Sung JJY, Ng SC. Significant Medical and Surgical Morbidity in Perianal Crohn's Disease: Results from a Territory-Wide Study. J Crohns Colitis 2018; 12:1392-1398. [PMID: 30165543 DOI: 10.1093/ecco-jcc/jjy120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The presence of perianal fistulas in Crohn's disease [CD] denotes increased disease aggressiveness. We studied the epidemiology and clinical outcomes of perianal CD [PCD] using the Hong Kong territory-wide IBD Registry [HKIBDR]. METHODS Consecutive patients with PCD were identified from the HKIBDR, and disease characteristics, treatments, and outcomes were analysed. The risks for medical and surgical therapies were assessed using Kaplan-Meier analysis. RESULTS Among 981 patients with CD with 10530 patient-years of follow-up, 283 [28.8%] had perianal involvement, of which 120 [42.4%] were as first presentation. The mean age at diagnosis of PCD was 29.1 years, and 78.8% were male. The median follow-up duration was 106 months (interquartile range [IQR]: 65-161 months]. Perianal fistula [84.8%] and perianal abscess [52.7%] were the two commonest forms. Male, younger age at diagnosis of CD, and penetrating phenotypes were associated with development of PCD in multivariate analysis. Of 242 patients with fistulizing PCD, 70 [29.2%] required ≥5 courses of antibiotics, and 98 [40.5%] had ≥2 surgical procedures. Nine patients required defunctioning surgery and 4 required proctectomy. Eighty-four patients [34.7%] received biologics. Cumulative probabilities for use of biologics were 4.7%, 5.8%, and 8.6% at 12 months, 36 months, and 96 months, respectively, while the probabilities for surgery were 67.2%, 71.6%, and 77.7%, respectively. Five mortalities were recorded, including 2 cases of anal cancer, 2 CD-related complications, and one case of pneumonia. CONCLUSION Over 40% of CD patients presented with perianal disease at diagnosis. Patients with PCD had poor outcome, with young age of onset, multiple antibiotic use, and repeated surgery.
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Affiliation(s)
- Wing Yan Mak
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
| | - Oi Sze Mak
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
| | - Choon Kin Lee
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong.,Gastroenterology Unit, Department of Medicine, Hospital Pulau Pinang, Pulau Pinang, Malaysia
| | - Whitney Tang
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
| | - Wai Keung Leung
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Marc T L Wong
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | | | - Michael Li
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong
| | - Chi Man Leung
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Fu Hang Lo
- Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong
| | - Belsy C Y Lam
- Department of Medicine and Geriatrics, Kwong Wah Hospital, Hong Kong
| | - Kam Hon Chan
- Department of Medicine, North District Hospital, Hong Kong
| | | | | | - Aric J Hui
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Wai Hung Chow
- Department of Medicine, Yan Chai Hospital, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
| | - Joseph J Y Sung
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
| | - Siew C Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong
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Abstract
BACKGROUND Pelvic MRI allows for clear delineation of anatomy in Crohn's fistula-in-ano, although its interpretation is often difficult for nonradiologists. OBJECTIVE The aim was to develop a 3-dimensional model where fistula tracts and their relationship to the sphincter complex can be accurately defined, which can then be rotated in multiple axes by the surgeon. DESIGN A 3-dimensional model was created based on MRI images. An additional 3-dimensional T2-weighted sequence was added to the existing MRI protocol to obtain high-resolution images. Segmentation of the fistula tract and volume rendering of the segmented tract were performed to create the final model. SETTINGS This was a single-center study conducted in Victoria, Australia. PATIENTS All of the patients who had pelvic MRI for fistulating Crohn's disease between March 2016 and March 2017 had the additional MRI sequence. INTERVENTIONS Postprocessing of MRI images was performed by a single radiologist. RESULTS Total acquisition time for MRI images was extended to 31 minutes compared with the standard 2-dimensional protocol lasting 25 minutes. Additional postprocessing time used to create the model was ≈15 minutes. Two clinical vignettes using this model are presented and compared with conventional 2-dimensional MRI images to highlight the use of the 3-dimensional modeling technique. LIMITATIONS This technique involves a semiautomatic process of fistula tract segmentation that requires radiologist expertise and additional postprocessing time. CONCLUSIONS This 3-dimensional modeling technique enables accurate identification of tracts in Crohn's fistula-in-ano and improves spatial orientation for the surgeon. The model has the potential to be an invaluable preoperative tool to guide operative decision-making, as well as enabling the assessment of response to medical or surgical therapy.
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25
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Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.
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Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shailja Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David B Sachar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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26
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Adegbola SO, Pisani A, Sahnan K, Tozer P, Ellul P, Warusavitarne J. Medical and surgical management of perianal Crohn's disease. Ann Gastroenterol 2018; 31:129-139. [PMID: 29507460 PMCID: PMC5825943 DOI: 10.20524/aog.2018.0236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/24/2017] [Indexed: 12/16/2022] Open
Abstract
Crohn's disease is increasingly thought to encompass multiple possible phenotypes. Perianal manifestations account for one such phenotype and represent an independent disease modifier. In its more severe form, perianal Crohn's disease confers a higher risk of a severe and disabling disease course, relapses, hospital admissions and operations. This, in turn, imposes a considerable burden and disability on patients. Identification of the precise manifestation is important, as management is nuanced, with both medical and surgical components, and is best undertaken in a multidisciplinary setting for both diagnosis and ongoing treatment. The introduction of biologic medication has heralded a significant addition to the management of fistulizing perianal Crohn's disease in particular, albeit with modest results. It remains a very challenging condition to treat and further work is required to optimize management in this group of patients.
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Affiliation(s)
- Samuel O. Adegbola
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
| | - Anthea Pisani
- Department of Gastroenterology, Mater dei Hospital, Malta (Pierre Ellul)
| | - Kapil Sahnan
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
| | - Phil Tozer
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
| | - Pierre Ellul
- Department of Gastroenterology, Mater dei Hospital, Malta (Pierre Ellul)
| | - Janindra Warusavitarne
- Department of Colorectal Surgery St. Mark’s Hospital, Harrow, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phil Tozer, Janindra Warusavitarne)
- Department of Surgery and Cancer, Imperial College, London, United Kingdom (Samuel O. Adegbola, Kapil Sahnan, Phillip Tozer, Janindra Warusavitarne)
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27
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Abstract
Inflammatory bowel disease (IBD) includes 2 chronic idiopathic inflammatory diseases: ulcerative colitis and Crohn disease. The incidence and prevalence of IBD is increasing worldwide. It can affect people of all ages, including children and geriatric populations, and can impact all aspects of life. In this article, diagnosis and treatment of IBD in adults, pediatric, pregnant, and elderly populations are explored from the perspective of a primary care physician.
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Affiliation(s)
- Tomoko Sairenji
- Department of Family Medicine, University of Washington, 1959 Northeast Pacific Street E-304, Seattle, WA 98195-6390, USA.
| | - Kimberly L Collins
- Department of Family Medicine, University of Washington, 331 NE Thornton Place, Seattle, WA 98125, USA
| | - David V Evans
- Department of Family Medicine, University of Washington, 1959 Northeast Pacific Street E-304, Seattle, WA 98195-6390, USA
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28
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Thomassin L, Armengol-Debeir L, Charpentier C, Bridoux V, Koning E, Savoye G, Savoye-Collet C. Magnetic resonance imaging may predict deep remission in patients with perianal fistulizing Crohn's disease. World J Gastroenterol 2017; 23:4285-4292. [PMID: 28694669 PMCID: PMC5483503 DOI: 10.3748/wjg.v23.i23.4285] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/03/2017] [Accepted: 05/09/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate the imaging course of Crohn’s disease (CD) patients with perianal fistulas on long-term maintenance anti-tumor necrosis factor (TNF)-α therapy and identify predictors of deep remission.
METHODS All patients with perianal CD treated with anti-TNF-α therapy at our tertiary care center were evaluated by magnetic resonance imaging (MRI) and clinical assessment. Two MR examinations were performed: at initiation of anti-TNF-α treatment and then at least 2 years after. Clinical assessment (remission, response and non-response) was based on Present’s criteria. Rectoscopic patterns, MRI Van Assche score, and MRI fistula activity signs (T2 signal and contrast enhancement) were collected for the two MR examinations. Fistula healing was defined as the absence of T2 hyperintensity and contrast enhancement on MRI. Deep remission was defined as the association of both clinical remission, absence of anal canal ulcers and healing on MRI. Characteristics and imaging patterns of patients with and without deep remission were compared by univariate and multivariate analyses.
RESULTS Forty-nine consecutive patients (31 females and 18 males) were included. They ranged in age from 14-70 years (mean, 33 years). MRI and clinical assessment were performed after a mean period of exposure to anti-TNF-α therapy of 40 ± 3.7 mo. Clinical remission, response and non-response were observed in 53.1%, 20.4%, and 26.5% of patients, respectively. Deep remission was observed in 32.7% of patients. Among the 26 patients in clinical remission, 10 had persisting inflammation of fistulas on MRI (T2 hyperintensity, n = 7; contrast enhancement, n = 10). Univariate analysis showed that deep remission was associated with the absence of rectal involvement and the absence of switch of anti-TNF-α treatment or surgery requirement. Multivariate analysis demonstrated that only the absence of rectal involvement (OR = 4.6; 95%CI: 1.03-20.5) was associated with deep remission.
CONCLUSION Deep remission is achieved in approximately one third of patients on maintenance anti-TNF-α therapy. Absence of rectal involvement is predictive of deep remission.
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29
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Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS. Association of Coloproctology of Great Britain and Ireland consensus exercise on surgical management of fistulating perianal Crohn's disease. Colorectal Dis 2017; 19:418-429. [PMID: 28387062 DOI: 10.1111/codi.13672] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/04/2017] [Indexed: 02/08/2023]
Abstract
AIM Management of fistulating perianal Crohn's disease (fpCD) is a significant challenge for a colorectal surgeon. A recent survey of surgical practice in this condition showed variation in management approaches. As a result we set out to devise recommendations for practice for UK colorectal surgeons. METHOD Results from a national survey were used to devise a set of potential consensus statements. Consultant colorectal surgeons were invited to participate in the exercise via the previous survey and the mailing list of the professional society. Iterative voting was performed on each statement using a five-point Likert scale and electronic voting, with opportunity for discussion and refinement between each vote. Consensus was defined as > 80% agreement. RESULTS Seventeen surgeons and two patient representatives voted upon 51 statements. Consensus was achieved on 39 items. Participants advocated a patient-centred approach by a colorectal specialist, within strong multidisciplinary teamworking. The use of anti-TNFα therapy is advocated. Where definitive surgical techniques are considered they should be carefully selected to avoid adverse impact on function. Ano/rectovaginal fistulas should be managed by specialists in fistulating disease. Stoma or proctectomy could be discussed earlier in a patient's treatment pathway to improve choice, as they may improve quality of life. CONCLUSION This consensus provides principles and guidance for best practice in managing patients with fpCD.
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Affiliation(s)
- M J Lee
- Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK.,Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - N Heywood
- University Hospital South Manchester, Manchester, UK
| | - P M Sagar
- St James University Hospital, Leeds, UK
| | - S R Brown
- Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
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30
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Lee MJ, Heywood N, Sagar PM, Brown SR, Fearnhead NS. Surgical management of fistulating perianal Crohn's disease: a UK survey. Colorectal Dis 2017; 19:266-273. [PMID: 27423057 DOI: 10.1111/codi.13462] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/08/2016] [Indexed: 12/13/2022]
Abstract
AIM Around one-third of patients with Crohn's disease are affected by Crohn's fistula-in-ano (pCD). It typically follows a chronic course and patients undergo long-term medical and surgical therapy. We set out to describe current surgical practice in the management of pCD in the UK. METHOD A survey of surgical management of pCD was designed by an expert group of colorectal surgeons and gastroenterologists. This assessed acute, elective, multidisciplinary and definitive surgical management. A pilot of the questionnaire was undertaken at the 2015 meeting of the Digestive Disease Federation. The survey was refined and distributed nationally through the trainee collaborative networks. RESULTS National rollout obtained responses from 133 of 179 surgeons approached (response rate 74.3%). At first operation, 32% of surgeons would always consider drainage of sepsis and 31.1% would place a draining seton. At first elective operation, 66.6% would routinely insert of draining seton, and 84.4% would avoid cutting seton. An IBD multidisciplinary team was available to 87.6% of respondents, although only 25.1% routinely discussed pCD patients. Anti-tumour necrosis factor-alpha therapy was routinely considered by 64.2%, although 44.2% left medical management to gastroenterologists. Common definitive procedures were removal of the seton only (70.7%), fistulotomy (57.1%), advancement flap (38.9%), fistula plug (36.4%) and ligation of intersphincteric track (LIFT) procedure (31.8%). Indications for diverting stoma or proctectomy were intractable sepsis, incontinence and poor quality of life. CONCLUSION This survey has demonstrated areas of common practice, but has also highlighted divergent practice including choices of definitive surgery and multimodal management. Practical guidelines are required to support colorectal surgeons in the UK.
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Affiliation(s)
- M J Lee
- Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK.,Department of Oncology and Metabolism, Medical School, University of Sheffield, Sheffield, UK.,South Yorkshire Surgical Research Group, Department of General Surgery, Northern General Hospital, Sheffield, UK
| | - N Heywood
- University Hospital South Manchester, Manchester, UK.,North-West Research Collaborative, University Hospital South Manchester, Manchester, UK
| | - P M Sagar
- St James University Hospital, Leeds, UK
| | - S R Brown
- Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
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31
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Abdalla SM, Kalra G, Moshiree B. Motility Evaluation in the Patient with Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2016; 26:719-38. [PMID: 27633599 DOI: 10.1016/j.giec.2016.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with inflammatory bowel disease (IBD) suffer frequently from functional bowel diseases (FBD) and motility disorders. Management of FBD and motility disorders in IBD combined with continued treatment of a patient's IBD symptoms will likely lead to better clinical outcomes and improve the patient's quality of life. The goals of this review were to summarize the most recent literature on motility disturbances in patients with IBD and to give a brief overview of the ranges of motility disturbances, from reflux disease to anorectal disorders, and discuss their diagnosis and specific management.
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Affiliation(s)
- Sherine M Abdalla
- Department of Medicine, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Central Building, 600D, Miami, FL 33136, USA
| | - Gorav Kalra
- Department of Medicine, Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB, 11th Floor, Miami, FL 33136, USA
| | - Baha Moshiree
- Department of Medicine, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB Suite 971, Miami, FL 33136, USA.
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32
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Dawson H, Serra S. Tumours and inflammatory lesions of the anal canal and perianal skin revisited: an update and practical approach. J Clin Pathol 2015; 68:971-81. [DOI: 10.1136/jclinpath-2015-203056] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tumours of the anal and perianal region are relatively rare, and clinically often interpreted as innocuous lesions, leading to frequent delays in diagnosis and adequate treatment. Although squamous cell neoplasia represents the most common entity encountered in this anatomically complex area, many conditions, both neoplastic and inflammatory, may occur. Adding to the challenge of correct diagnosis and patient management, recent years have seen major updates in the terminology of squamous cell neoplasia, created to reflect advances in our understanding of the role of human papilloma virus and unify previous terminologies used for different sites in the anogenital tract. However, squamous cell neoplasia in the anal canal and perianal region may differ in terms of histology, biological behaviour, staging and treatment. The aim of this review is to present an overview of neoplastic and non-neoplastic lesions that may be seen in this area, an update on important developments and terminology, potential pitfalls that may be encountered in routine pathology practice and a practical approach on how to resolve these issues.
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33
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de la Portilla F, Durán V, Maestre MV, Díaz-Pavón JM, Vázquez-Monchul JM, Palacios C, Gollonet JL, Sánchez-Gil JM. Effectiveness of a three-dimensional anorectal ultrasound in perianal Crohn's disease: incompatibility with clinical and surgical examinations. Int J Colorectal Dis 2015; 30:529-34. [PMID: 25526856 DOI: 10.1007/s00384-014-2102-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE We have correlated the 3D anorectal ultrasound (3D ARU) findings with clinical examination and the surgical findings and examined its capacity to provide ancillary information, which potentially alters patient management. PATIENTS AND METHODS This is a prospective analysis conducted at a tertiary academic hospital. A total of 95 patients were included. We screened for sphincter defects and the presence of perianal Crohn's disease (PACD)-related lesions. RESULTS We performed 150 3D ARUs. Exploratory ultrasound coincided with the rationale for diagnosis in 67.7% of cases, and fistulae were detected in 79% of cases where there was clinical suspicion. Fistulae were associated with abscesses in 29 cases, and isolated abscesses were identified in 19 cases (17.7%), only 12 of which (63.2%) were clinically suspected. Sphincter defects were observed in 15 cases with 7 cases (77.8%) presenting with clinical fecal incontinence. The operative findings coincided with ultrasonographic findings in 81.3% of the analyzed cases. The inter-observer variability of endosonographic classification resulted in a kappa score of 0.86. Ultrasonographic data altered the therapeutic plan of management in 73 cases (48.6%). CONCLUSIONS Three-dimensional ARU is accurate in the diagnosis of fistula type in PACD and in the delineation of ancillary suspected and unsuspected abscess collections. Its use impacts therapeutic management in about half the cases examined. A new ultrasonographic-based PACD classification system is presented which has high inter-observer agreement but which requires future prospective validation in clinical PACD patients.
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Affiliation(s)
- F de la Portilla
- Coloproctology Unit, Unidad de Gestión Clínica de Cirugía General y del Aparato Digestivo, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, Seville, 41013, Spain,
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Juncadella AC, Alame AM, Sands LR, Deshpande AR. Perianal Crohn’s disease: A review. Postgrad Med 2015; 127:266-72. [DOI: 10.1080/00325481.2015.1023160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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35
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Sordo-Mejia R, Gaertner WB. Multidisciplinary and evidence-based management of fistulizing perianal Crohn's disease. World J Gastrointest Pathophysiol 2014; 5:239-51. [PMID: 25133026 PMCID: PMC4133523 DOI: 10.4291/wjgp.v5.i3.239] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 05/07/2014] [Accepted: 05/28/2014] [Indexed: 02/06/2023] Open
Abstract
Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.
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36
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37
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Cutaneous manifestations in patients with inflammatory bowel diseases: pathophysiology, clinical features, and therapy. Inflamm Bowel Dis 2014; 20:213-27. [PMID: 24105394 DOI: 10.1097/01.mib.0000436959.62286.f9] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The skin is one of the most common extraintestinal organ system affected in patients with inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis. The skin manifestations associated with IBD are polymorphic and can be classified into 4 categories according to their pathophysiology: (1) specific, (2) reactive, (3) associated, and (4) induced by IBD treatment. Cutaneous manifestations are regarded as specific if they share with IBD the same granulomatous histopathological pattern: perianal or metastatic Crohn's disease (commonly presenting with abscesses, fistulas or hidradenitis suppurativa-like features) is the prototype of this setting. Reactive cutaneous manifestations are different from IBD in the histopathology but have close physiopathological links: pyoderma gangrenosum, a neutrophil-mediated autoinflammatory skin disease typically manifesting as painful ulcers, is the paradigm of this group. Among the cutaneous diseases associated with IBD, the most commonly seen are erythema nodosum, a form of panniculitis most commonly involving bilateral pretibial areas, and psoriasis, a T helper 1/T helper 17-mediated erythematous squamous inflammatory disease. Finally, the number of cutaneous adverse reactions because of IBD therapies is progressively increasing. The most frequent drug-induced cutaneous manifestations are psoriasis-like, eczema-like, and lichenoid eruptions, as well as cutaneous lupus erythematosus for biologics, and nonmelanoma skin cancer, mainly basal cell and squamous cell carcinomas for thiopurines.
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38
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Abstract
The rectum and anus are two anatomically complex organs with diverse pathologies. This article reviews the basic anatomy of the rectum and anus. In addition, it addresses the current radiographic techniques used to evaluate these structures, specifically ultrasound, magnetic resonance imaging, and defecography.
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Affiliation(s)
- Patrick Solan
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
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39
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Norton C, Dibley LB, Bassett P. Faecal incontinence in inflammatory bowel disease: associations and effect on quality of life. J Crohns Colitis 2013; 7:e302-11. [PMID: 23228710 DOI: 10.1016/j.crohns.2012.11.004] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 11/12/2012] [Accepted: 11/13/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS No previous study has reported on faecal incontinence (FI) amongst people with IBD. We aimed to determine the frequency and severity of FI in people with IBD, its association with known FI risk factors, and the effect on quality of life. METHOD We randomly sampled 10,000 members of a national Crohn's and Colitis organisation over 18years old. Demographic information, medical history, FI (ICIQ-B), urinary continence (ICIQ-UI), quality of life (IBD-Q) and free text responses about FI were collected. Current disease activity was reported using the Harvey Bradshaw Index for Crohn's Disease (CD), and the Walmsley Index for ulcerative colitis (UC). Data were managed using Excel, Stata and SPSS 18. RESULTS 4827 responses were received: 3264 were complete and included (32.6% response). 2178 respondents were female (66.7%); mean age 50.26 yrs (range 19-92); CD 1543 (46.98%); UC 1599 (48.97%); other IBD 126 (3.85%); no diagnosis given 6 (0.18%). 74% (2391) of respondents reported FI (95% CI 72-75). Nine percent (299) reported regular FI. No association was found between FI and diagnosis. Significant associations were found in multivariable analysis between FI and age (p=0.005), gender (p<0.001), anal stretch (p=0.004), anal fistula surgery (p<0.001), colo-rectal surgery (p=<0.001), and urinary incontinence (p=<0.001), but not with vaginal delivery. Quality of life was significantly affected by FI (p<0.001). CONCLUSION Even if all non-respondents are continent, FI affects 24% of people with IBD. In our sample 74% reported FI, which can occur without active disease. There is a large currently unmet need for continence care in people with IBD.
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Affiliation(s)
- Christine Norton
- King's College, London & Imperial College Healthcare NHS Trust, London, United Kingdom.
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Abstract
Crohn disease involves the perineum and rectum in approximately one-third of patients. Symptoms can range from mild, including skin tags and hemorrhoids, to unremitting and severe, requiring a proctectomy in a small, but significant, portion. Fistula-in-ano and perineal sepsis are the most frequent manifestation seen on presentation. Careful diagnosis, including magnetic resonance imaging or endorectal ultrasound with examination under anesthesia and aggressive medical management, usually with a tumor necrosis factor-alpha, is critical to success. Several options for definitive surgical repair are discussed, including fistulotomy, fibrin glue, anal fistula plug, endorectal advancement flap, and ligation of intersphincteric fistula tract procedure. All suffer from decreased efficacy in patients with Crohn disease. In the presence of active proctitis or perineal disease, no surgical therapy other than drainage of abscesses and loose seton placement is recommended, as iatrogenic injury and poor wound healing are common in that scenario.
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Affiliation(s)
- Robert T. Lewis
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Joshua I. S. Bleier
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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Abstract
IMPORTANCE Treatment of Crohn disease is rapidly evolving, with the induction of novel biologic therapies and newer, often more intensive treatment approaches. Knowing how to treat individual patients in this quickly changing milieu can be a challenge. OBJECTIVE To review the diagnosis and management of moderate to severe Crohn disease, with a focus on newer treatments and goals of care. EVIDENCE REVIEW MEDLINE was searched from 2000 to 2011. Additional citations were procured from references of select research and review articles. Evidence was graded using the American Heart Association level-of-evidence guidelines. RESULTS Although mesalamines are still often used to treat Crohn disease, the evidence for their efficacy is lacking. Corticosteroids can be effectively used to induce remission in moderate to severe Crohn disease, but they do not maintain remission. The mainstays of treatment are immunomodulators and biologics, particularly anti-tumor necrosis factor. CONCLUSION AND RELEVANCE Immunomodulators and biologics are now the preferred treatment options for Crohn disease.
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Affiliation(s)
- Adam S Cheifetz
- Division of Gastroenterology, Rabb-Rose 425, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA.
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Garrick V, Stenhouse E, Haddock G, Russell RK. A multidisciplinary team model of caring for patients with perianal Crohn's disease incorporating a literature review, topical therapy and personal practice. Frontline Gastroenterol 2013; 4:152-160. [PMID: 28839719 PMCID: PMC5369793 DOI: 10.1136/flgastro-2012-100160] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 10/29/2012] [Accepted: 10/30/2012] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn's disease (CD) is characterised by periods of relapse and remission. Over time the disease leads almost inevitably to the complications of stricturing, penetration and fistulisation. Perianal CD involves areas of chronic abscess formation, ulceration, skin tags or fistula formation. This can be a particularly challenging and complex problem to manage, and a range of potential treatment modalities exist. METHODS This review covers the management of perianal CD and provides recommendations for practice for the multidisciplinary team (MDT), including the use of wound management products and relevant clinical images. RESULTS Current practice focuses predominantly on the use of antibiotic therapy, immunosuppression, immunomodulation and surgery. These therapies are used individually or in combination. The majority of evidence suggests that a combination of medical and surgical management produces the best disease outcomes. However, this treatment regime can be debilitating for the patient and compliance can be difficult. Published work on the use of topical therapy in the management of perianal CD focuses specifically on topical drug therapy; it does not, however, address the basic guiding principles of chronic wound management-in particular, optimal moisture control and the management of bacterial burden on the wound surface. Honey and silver-containing wound management products act as topical antimicrobial agents and therefore address these principles. CONCLUSIONS Perianal CD is the archetypal condition that exemplifies the need for an MDT approach in caring for patients with inflammatory bowel disease. A combination of treatment modalities that includes topical wound management is likely to produce the best patient outcomes.
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Affiliation(s)
- Vikki Garrick
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow, UK
| | - Emily Stenhouse
- Department of Paediatric Radiology, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow, UK
| | - Graham Haddock
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Yorkhill Hospital, Glasgow, UK
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D'Ugo S, Franceschilli L, Cadeddu F, Leccesi L, Blanco GDV, Calabrese E, Milito G, Di Lorenzo N, Gaspari AL, Sileri P. Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal. BMC Gastroenterol 2013; 13:47. [PMID: 23496835 PMCID: PMC3602071 DOI: 10.1186/1471-230x-13-47] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 02/28/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn's disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years. METHODS Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment. RESULTS Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications. CONCLUSIONS Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can't be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.
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Affiliation(s)
- Stefano D'Ugo
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Luana Franceschilli
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Federica Cadeddu
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Laura Leccesi
- Department of Internal Medicine, Catholic University, Rome, Italy
| | | | - Emma Calabrese
- Department of Gastroenterology, University Hospital Tor Vergata, Rome, Italy
| | - Giovanni Milito
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Nicola Di Lorenzo
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Achille L Gaspari
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Pierpaolo Sileri
- Department of Surgery, University Hospital Tor Vergata, Viale Oxford 81, Rome 00133, Italy
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Sexual function and quality of life after surgical treatment for anal fistulas in Crohn's disease. Tech Coloproctol 2012; 17:89-94. [PMID: 22956209 DOI: 10.1007/s10151-012-0890-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 08/07/2012] [Indexed: 01/03/2023]
Abstract
BACKGROUND The aim of this study was to assess sexual function and quality of life (QoL) in patients after surgery for perianal Crohn's disease. METHODS Eighty-eight consecutive patients with perianal Crohn's disease, operated on at the Medical University of Vienna, completed a self-administered questionnaire including the International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI), Short Form-12 Health Survey (SF-12), and the Inflammatory Bowel Disease Questionnaire (IBDQ). Patients with a current stoma were excluded from further analysis. The median follow-up time was 104 months (range 3-186 months). Healthy subjects served as controls for each case and were matched by age (±6 years) and gender. Forty-seven (68 %) female and 22 male patients with a median age of 46.5 years (range 18-64 years) were analyzed. Eleven (16 %) patients had simple and 58 (84 %) complex anal fistulas. RESULTS The median SF-12 physical health score of the patients was significantly lower (47.9 (range 25.5-57.2)) than that of the controls (54.3 (range 34.6-61.8); p = 0.03). Not surprisingly, the median total sore of the IBDQ of the controls was significantly better than that of the patients (controls: 188.5 (range 125-206.5), patients: 157 (range 60-199.5); p < 0.0001). Analysis with the multiple logistic regression test showed that type of operation, >1 perianal fistula opening, and active Crohn's disease were independent risk factors for a worse IBDQ (p = 0.03, p = 0.015 and p < 0.0001). Interestingly, the median FSFI and IIEF score were not found to be significant different in any domain. CONCLUSIONS QoL but not sexual function is significantly influenced by surgery for perianal Crohn's disease.
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Krieger BR, Steinhagen RM. Perianal Crohn's Disease—A Surgical Perspective. SEMINARS IN COLON AND RECTAL SURGERY 2012. [DOI: 10.1053/j.scrs.2012.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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El Safoury OS, Shaker OG, Fawzy MM. Skin tags and acanthosis nigricans in patients with hepatitis C infection in relation to insulin resistance and insulin like growth factor-1 levels. Indian J Dermatol 2012; 57:102-6. [PMID: 22615504 PMCID: PMC3352629 DOI: 10.4103/0019-5154.94275] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Skin tags (ST) are papillomas commonly found in the neck, axillae of middle-aged and elderly people AIM Insulin and insulin-like growth factor (IGF-1) levels are affected by hepatitis C virus (HCV) infection and both of them may be implicated in the etiopathogenesis of ST and acanthosis nigricans (AN) through their proliferative and differentiating properties. So, the aim of this work was to evaluate the impact of HCV infection on ST and AN through the estimation of insulin resistance and IGF-1. MATERIALS AND METHODS PARTICIPANTS WERE ARRANGED INTO FOUR GROUPS: (ST +ve / HCV +ve) 23 subjects, (ST+ / HCV -ve) 19 subjects, (HCV -ve / ST-ve) 20 subjects and (ST-ve /HCV +ve) 22 subjects. Age, ST size, color, number, AN, fasting glucose, fasting insulin, insulin resistance, IGF-1, HCV-antibodies (Ab) were recorded. RESULTS The mean number of ST in Group 1 was half the number of ST in Group 2 (11.0±9.3 / 22.3±14.0) (P=0.005). The difference in insulin resistance between the same groups was non-significant (13.1±10.6 / 9.0±5.5) (P=0.441) while the difference in IGF-1 was statistically significant (218.6±46.2 /285.4±32.8) (P=0.002). The multivariate logistic regression for the variables revealed that insulin resistance is the only factor affecting the occurrence of ST (OR=1.096, P=0.023). Multivariate regression analysis for the variables showed that HCV was borderline but not a significant factor affecting the number of ST (Beta=-0.409, P=0.053). The number of patients with AN was doubled in Group 2 in comparison to Group 1 but this was non significant 3(13%) / 6(32%) (P=0.2800). CONCLUSION HCV is associated with a significant decrease in the ST number and in the serum level of IGF-1 together with an obvious decrease in the occurrence of AN. Our results may point to the entrant effect of insulin resistance and IGF-1 in ST and AN development. The current study suggests the evaluation of IGF-1-lowering agents in the control of ST and AN especially in the females with polycystic ovary and in the prevention of the recurrence of ST after surgical removal.
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Baik SH, Kim WH. A comprehensive review of inflammatory bowel disease focusing on surgical management. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012; 28:121-31. [PMID: 22816055 PMCID: PMC3398107 DOI: 10.3393/jksc.2012.28.3.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 06/10/2012] [Indexed: 12/15/2022]
Abstract
The two main diseases of inflammatory bowel disease are Crohn's disease and ulcerative colitis. The pathogenesis of inflammatory disease is that abnormal intestinal inflammations occur in genetically susceptible individuals according to various environmental factors. The consequent process results in inflammatory bowel disease. Medical treatment consists of the induction of remission in the acute phase of the disease and the maintenance of remission. Patients with Crohn's disease finally need surgical treatment in 70% of the cases. The main surgical options for Crohn's disease are divided into two surgical procedures. The first is strictureplasty, which can prevent short bowel syndrome. The second is resection of the involved intestinal segment. Simultaneous medico-surgical treatment can be a good treatment strategy. Ulcerative colitis is a diffuse nonspecific inflammatory disease that involves the colon and the rectum. Patients with ulcerative colitis need surgical treatment in 30% of the cases despite proper medical treatment. The reasons for surgical treatment are various, from life-threatening complications to growth retardation. The total proctocolectomy (TPC) with an ileal pouch anal anastomosis (IPAA) is the most common procedure for the surgical treatment of ulcerative colitis. Medical treatment for ulcerative colitis after a TPC with an IPAA is usually not necessary.
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Affiliation(s)
- Seung Hyuk Baik
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Mahadev S, Young JM, Selby W, Solomon MJ. Self-reported depressive symptoms and suicidal feelings in perianal Crohn's disease. Colorectal Dis 2012; 14:331-5. [PMID: 21689304 DOI: 10.1111/j.1463-1318.2011.02613.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM Crohn's disease is a chronic inflammatory condition that has been associated with high rates of mental illness. Perianal lesions are prevalent; however, their specific impact on depression has not been studied. The aim of our study was to investigate the prevalence and associations of self-reported depressive symptoms in the subset of Crohn's patients with perianal disease. METHOD Patients with perianal Crohn's disease from one institution were surveyed to elicit the frequency of self-reported depressive symptoms. Patients completed a questionnaire and consented to medical records audit. RESULTS Of the 130 patients invited, 69 (53%) returned a survey. Depressive symptoms were self-reported at very high rates, with 73% reporting feeling depressed and 13% reporting feeling suicidal at some point. Associations were found between depressive symptoms and duration of disease, prior surgery, past or present stoma, and anal stenosis. Patients who self-reported depressive symptoms had lower overall utilities, and were willing to trade very significant proportions (upwards of 15%) of their life expectancy for disease cure. CONCLUSION This study suggests that many patients with perianal Crohn's disease experience significant emotional distress that impairs their overall quality of life. Further controlled studies are required to assess the impact of perianal disease and to address the need to target interventions to meet the mental health needs of this population.
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Affiliation(s)
- Srihari Mahadev
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Soucy G, Wang HH, Farraye FA, Schmidt JF, Farris AB, Lauwers GY, Cerda SR, Dendrinos KG, Odze RD. Clinical and pathological analysis of colonic Crohn's disease, including a subgroup with ulcerative colitis-like features. Mod Pathol 2012; 25:295-307. [PMID: 21841769 DOI: 10.1038/modpathol.2011.120] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Little is known regarding the clinical and, in particular, pathological manifestations of patients with isolated colonic Crohn's disease. The purpose of this study was to evaluate the clinical and pathological features of patients with Crohn's disease limited to the colon at initial presentation, and to determine whether there are any histological features that are predictive of outcome after surgery. The clinical features, outcome after surgery, and pathological features of colonic resection specimens of 73 patients who presented initially with isolated colonic Crohn's disease were evaluated and compared with 45 Crohn's disease patients who presented initially with both ileal and colonic involvement. Clinically, patients with isolated colonic Crohn's disease presented at a significantly older age at the time of diagnosis, and had a significantly shorter duration of colitis before surgical resection, than did patients with ileocolonic Crohn's disease at disease onset. Pathologically, patients with isolated colonic Crohn's disease showed a significantly higher proportion of cases with subtotal, total, or left-sided colitis, and significantly fewer strictures/stenosis, pericolonic adhesions, pyloric metaplasia, and cases with proximal worse than distal colonic disease. Overall, patients with isolated colonic Crohn's disease showed a trend toward a lower number of major microscopic Crohn's disease features. A small proportion of patients from both Crohn's disease groups (14% and 13%, respectively) showed inflammatory disease limited to the mucosa, without mural involvement, reminiscent of ulcerative colitis, and these were termed 'ulcerative colitis-like Crohn's disease'. These patients were significantly younger than those with mural involvement. Overall, 44% of patients from both Crohn's disease groups developed at least one adverse outcome, and neither the number nor the type of major Crohn's disease features correlated with adverse outcome. Patients with isolated colonic involvement have distinctive clinical and pathological features. A small subgroup of Crohn's patients shows only mucosal involvement reminiscent of ulcerative colitis.
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Affiliation(s)
- Genevieve Soucy
- Department of Pathology, Centre Hospitalier Universitaire de Montreal, Montreal, Quebec, Canada
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Abstract
Endoanorectal ultrasonography (EARUS) may be used for diagnosing various anorectal disorders. EARUS is easy to perform, has a short learning curve, and causes less discomfort than routine digital examination. Anal sphincters can be clearly visualized, and one can easily distinguish between the internal (hypoechoic) and external (hyperechoic) anal sphincters. Other pelvic floor structures, like the puborectalis muscle, can also be visualized. The use of contrast agents can increase the accuracy of EARUS in the assessment of perianal fistulae. In addition, EARUS is an excellent alternative to expensive magnetic resonance imaging. Besides its use in incontinence and perianal sepsis, the presence of slight or massive submucosal invasion in early rectal cancer may be imaged in greater detail. With 3-dimensional EARUS, it is possible to diagnose the anorectal diseases, in multiplane, with high spatial resolution, adding important information about the therapeutic decision. The normal sonographic anatomy of the anorectum, sonographic findings of anorectal diseases, and indications and limitations of endosonography with complementary techniques such as transvaginal and transperineal ultrasound are reviewed in this article.
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