From the Guidelines
Treatment for fistulizing disease in a stable inpatient with Crohn's disease and formed stools is primarily medical management with biologic agents, such as TNF-α antagonists, with infliximab being the most robustly supported option.
Medical Management
- The use of TNF-α antagonists, such as infliximab, is recommended for the treatment of fistulizing Crohn's disease, with infliximab having the most robust evidence supporting its use 1.
- Other biologic agents, including adalimumab, ustekinumab, and vedolizumab, have also shown efficacy in treating fistulizing disease, although the evidence is not as strong as for infliximab 1.
- Thiopurines and methotrexate may be used as adjunctive treatments, but are not recommended as first-line therapy for induction of remission 1.
Surgical Management
- Surgical intervention, such as fistulotomy, advancement flap, and fistula plug, may be considered in select patients with perianal Crohn's disease, but is generally reserved for cases where medical management has failed or is not feasible 1.
- Surgical drainage of sepsis is the first line therapy before initiating immunosuppressive treatment, and definitive surgical repair of fistulas is only considered in the absence of luminal inflammation 1.
Treatment Approach
- A multidisciplinary approach to management, including medical and surgical treatment, is recommended for optimal outcomes in patients with perianal fistulizing Crohn's disease 1.
- Early introduction of biologic agents, such as TNF-α antagonists, is suggested, rather than delaying their use until after failing other treatments 1.
From the Research
Treatment Options for Fistulizing Crohn's Disease
The treatment for fistulizing Crohn's disease in a stable inpatient with formed stools typically involves a combination of medical and surgical approaches.
- The first line of medical therapy includes antibiotics such as metronidazole and ciprofloxacin 2, 3.
- Immunomodulators like mercaptopurine and azathioprine are also effective in treating fistulizing Crohn's disease 2, 4.
- Anti-TNF-alpha agents, such as infliximab, are considered the gold standard for inducing and maintaining remission in fistulizing Crohn's disease, with a clinical response rate of 62% and a complete closure rate of 46% 2.
- Infliximab has been shown to be effective in maintaining remission, with 46% of patients continuing to respond to treatment at 54 weeks, compared to 23% in the placebo group 2.
Surgical Interventions
Surgical interventions are typically reserved for cases with perianal sepsis, abscesses, refractory disease, or complications of fistulas.
- Surgical drainage with or without seton placement, transient ileostomy, or proctectomy may be necessary in severe cases 5, 3, 4.
- The classification of fistulas in patients with Crohn's disease remains poorly defined, and a better classification system is needed to compare available studies 3.
Individualized Treatment Approach
The treatment of fistulizing Crohn's disease should be defined on an individual basis, taking into account the severity of symptoms, fistula location, and the presence of rectal complications 6, 4.
- Asymptomatic internal fistulas may not require intervention, while symptomatic perianal fistulas may require antibiotics, immunosuppressant therapy, or anti-TNF agents 3, 4.
- A diagnostic approach including examination under anesthesia, endoscopy, and imaging studies like MRI or EUS is essential before initiating treatment 4.