gutsandgrowth

Home | About Jay Hochman -Pediatric Gastroenterology Blog | Archives

Pediatric Consensus Statement: Perianal Crohn Disease

September 23, 2013 7:00 am

A recent report provides a useful reference for the often difficult care of pediatric perianal Crohn disease (JPGN 2013; 57: 401-412).

The statement reviews the background, etiology, presentation and classification systems. Most helpful are Figures 2 & 3.

Figure 2 provides an algorithm for assessment and treatment of perianal fistula.

History/Physical (including rectal exam for stricture) along with colonoscopy
Next either exam under anesthesia (with or without endoscopic ultrasound) or MRI
Main treatments:

consider antibiotics, anti-TNF, and immunomodulators
in some cases a noncutting seton or fistulotomy will be needed
consider advancement flap in rectovaginal fistulae

Figure 3 provides an algorithm for assessment and treatment of perianal abscess.

History/Physical (including rectal exam for stricture) along with colonoscopy
Next either exam under anesthesia (with or without endoscopic ultrasound) or MRI
Main treatments:

Incision and drainage
Noncutting seton if perianal fistula
Antibiotics
Treatment of intestinal disease

After outlining these algorithms, the report details the treatments. Almost all treatments that are effective or questionable for Crohn’s disease are discussed. The report reiterates that ‘corticosteroids must be used with caution in treatment of perianal fistula; studies have shown worse fistula outcomes for steroid-treated patients.

With regard to noncutting setons, the authors note that they do not prevent treatment with biologic agents and help prevent abscess formation. They “usually deteriorate and fall out on their own in about 1 year.” Medical therapy often allows for seton removal.

Ostomy diversion can be helpful in patients with severe perianal disease; however, “the risk of the ostomy becoming permanent is significant.”

Rectal strictures are typically dilated with multiple sessions with general anesthesia. The goal is at least 18 mm in younger patients and at least 24 mm in adolescents.

Related blog post:

Paris Classification of Pediatric Crohn’s Disease | gutsandgrowth

Previous references:

-Clin Gastro & Hep 2010; 8: 13. Another algorithm. For simple fistula, Rx w abx & medical (thiopurine or Remicade). If not better, fistulotomy, &/or Rx as complex fistula. For complex fistula, seton placement, abx, anti-TNF. If not better, consider tacrolimus or proctectomy.
-JPGN 2010; 50: 99. Perianal dz in young children may be due to autoimmune neutropenia.
-Clin Gastro & Hep 2009; 7: 1037. MRI study of choice for perianal fistulas. Algorithm: If superficial fistula, Rx c fistulotomy & Abx If deeper, noncutting seton c Abx, 6-MP +/- infliximab; if not effective, try tacrolimus; if not effective, surgery
-Ann Intern Med 2001; 135: 906-918.
-IBD 2008; 14: 1236. Anal skin tag description
-JPGN 2005; 41: 667. Discusses several cases of highly destructive perianal dz. -Gastro 2003; 125: 1503-1507, 1508-1530. Technical review.
-Gastro 2003; 125: 291. Bourne test to detect occult bladder fistula. Following nondiagnostic barium enema, urine can be collected, centrifuged, and xrayed to determine if there is a connection.