The American College of Colorectal Surgeons has published clinical practice guidelines for the management of patients with cryptoglandular, rectovaginal, and anorectal fistulas in the presence of Crohn’s disease.
“The generally accepted explanation for the cause of anorectal abscesses and intraanal fistulas is that abscesses are caused by obstruction of the anal gland, and fistulas are caused by chronic infection and epithelialization of the abscess drainage tract.” Wolfgang B. Gertner, MD, MSc; Professors and colleagues in the Department of Colorectal Surgery at the University of Minnesota wrote: colon disease & Rectum.
“Unlike occult glands, anorectal abscesses and intraanal fistulas may be symptoms of Crohn’s disease,” the researchers added. “In Crohn’s disease, anorectal abscesses and anorectal fistulas appear to result from osmotic inflammation rather than infection of the anorectal glands. Patients with fistulas associated with Crohn’s disease are usually managed with a multidisciplinary approach. Masu.”
The incidence of intraanal fistulas in CD patients ranges from 10% to 20% in population-based studies and 50% in longitudinal studies. The authors note that approximately 80% of her CD patients treated at tertiary referral centers may have a history of intravenous fistula.
Based on the last clinical practice guideline for the management of anorectal abscesses and intraanal fistulas published in 2016, committee members conducted a literature review of 269 sources and identified 25 guidelines for fistula patients in whom CD is present. The latest treatment guidelines have been formulated.
Key points regarding the evaluation strategy and management of anorectal abscess, anal fistula, rectovaginal fistula, and anorectal fistula-associated CD include:
- Initial evaluation of anorectal abscesses and anorectal fistulas should include an examination of the patient’s disease-specific medical history and a physical examination for the location of the abscess and fistula and the presence of secondary cellulitis.
- Although not always necessary, diagnostic imaging may be considered in some patients with occult anorectal abscesses, recurrent or complicated anal fistulas, immunosuppression, or anorectal-related CD.
- Acute anorectal abscesses must be treated immediately by incision and drainage. Antibiotics may be used only in patients with cellulitis, signs of systemic infection, or abscesses complicated by immunosuppression.
- Open fistulotomy or endorectal advancement flaps are recommended for treatment of patients with simple endoanal fistulas and normal anal sphincter function.
- Although endorectal advancement flaps with or without sphincteroplasty are the preferred procedure for most patients with rectovaginal fistulas, drainage seton may facilitate resolution of associated acute inflammation and infection in these patients. there is.
- Drainage setons are typically useful in the treatment of fistulizing anorectal CD and can also be used for long-term disease management.
- In cases of endoanal fistula associated with CD, an endorectal advancement flap and ligation of the intersphincteric fistula tract may be used.
- Complicated anorectal fistula formation In patients whose symptoms from CD are uncontrolled, stool modification or rectal resection may be necessary.
“These guidelines should not be considered to include all appropriate methods of care or to exclude methods of care reasonably directed to achieve the same results,” Gartner et al. is writing. “The final judgment regarding the appropriateness of a particular procedure must be made by the physician, considering all the circumstances presented by the individual patient.”
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Disclosure: Gartner reports financial relationships with Applied Medical, Becton Dickinson, Coloplast, and Intuitive Surgical. Please refer to this study for relevant financial disclosures of all other authors.