From the Guidelines
The correct answer is (b) fistulas are usually multiple. Perianal Crohn's disease is characterized by multiple fistulous tracts that develop as a manifestation of the inflammatory bowel condition. This feature is distinctive of perianal Crohn's, with studies showing that approximately 20-40% of patients with Crohn's disease develop perianal fistulas, and these fistulas are often multiple 1. Contrary to option (a), perianal disease often presents early in the course of Crohn's disease and may even be the initial manifestation before intestinal symptoms appear. Regarding option (c), fecal diversion provides temporary improvement but is rarely curative, with most patients experiencing recurrence after restoration of intestinal continuity, as seen in the classification of perianal fistulising Crohn's disease 1. For option (d), perianal Crohn's lesions are typically located in various positions, but the exact location is not a distinctive feature. As for option (e), granulomas are actually frequently found on biopsy of perianal lesions, making them an important diagnostic feature. The multiple fistulas in perianal Crohn's reflect the transmural inflammation characteristic of the disease, which allows for penetration through the intestinal wall and formation of abnormal connections between the rectum or anus and the perianal skin.
Some key points to consider in the management of perianal Crohn's disease include:
- Classification of perianal fistulising Crohn's disease into different classes based on disease severity and symptoms 1
- The use of medical and surgical therapy to manage symptoms and induce remission 1
- The importance of early diagnosis and treatment to prevent complications and improve quality of life 1
- The role of fecal diversion in temporary improvement, but not as a curative measure 1
Overall, the management of perianal Crohn's disease requires a multidisciplinary approach, taking into account the severity of symptoms, disease extent, and patient goals, as outlined in the ECCO guidelines on therapeutics in Crohn's disease: surgical treatment 1.
From the Research
Perianal Crohn's Disease Characteristics
- Perianal Crohn's disease can occur at any time in the course of the disease, not typically late 2
- Fistulas in perianal Crohn's disease can be simple or complex, and may be single or multiple 3, 2
- Fecal diversion is not usually curative, but may be considered in refractory cases 2
- Lesions in perianal Crohn's disease can be located in various positions, not typically posteriorly 3, 2
- Granulomas may be found on biopsy in some cases of perianal Crohn's disease, but this is not a definitive characteristic 4, 5
Treatment Options
- Medical management, including biologics and thiopurines, is often used to treat perianal Crohn's disease 5, 6
- Surgical management, including drainage of abscesses and placement of setons, may be necessary in some cases 3, 6
- Definitive surgical therapies, such as fistulotomies and advancement flaps, may be considered once the patient's inflammatory burden is well managed 6
- Stem cell therapy is a newer option being explored for the treatment of perianal fistula in Crohn's disease 6