High Frequency of Asymptomatic Perianal Crohn’s Disease at Diagnosis

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M Antaya et al. AJG; DOI: 10.14309/ajg.0000000000003733 (ahead of print); The impact of integrating pelvic MRI at diagnosis on early detection of perianal Crohn’s disease in pediatrics

Methods: “Patients [n=139] were prospectively enrolled into the Edmonton Pediatric Inflammatory Bowel Disease Clinic (EPIC) registry (baseline pelvic MR since 2018). A retrospective review (2018-2023) was performed.”

Key findings:

  • Nearly 1 in 3 (31%) newly diagnosed pediatric CD patients had perianal CD identified on pelvic MRI
  • Overall, 19% (n=27/139) had subclinical perianal disease (MR+/ asymptomatic (ASx)).
  • For patients who were both asymptomatic and had a normal perianal exam (n=86/139, 62%), their subclinical perianal disease rate was similar at 20% (n=17/86)
  • One in ten pediatric CD patients needed perianal surgery within the first 6 years post-diagnosis
  • MR+/ASx also had higher rates and faster time to perianal surgery than MR-/ASx (p=0.02)
  • Perianal side branch fistula was a predictor of surgery (OR 107.6, [95% CI 16.9-2178] p<0.0001)
  • In this study from Canada, 78% (n=108/139) were receiving biologic therapy at one year following diagnosis. However, only 51% (n=71/139) received biologic therapy as initial maintenance therapy

In their discussion, the authors indicate that pelvic MRI “enables identification of patients who may benefit from earlier biologic therapy (particularly anti-TNF) and closer monitoring despite being asymptomatic, given they have an increased risk of perianal surgery.” They note potential concerns for cost-effectiveness but note routine MRI may reduce future hospitalizations and surgery.

My take: In patients who will receive early biologic therapy, it is not likely that routine MRI will result in any cost savings. However, in settings without significant resource constraints, understanding the extent of disease is still desirable for later comparison.

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