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home - IBD - Treatment - Perianal Fistulas Written by Dr Sebastian Zeki

Knows the criteria for assessing the severity and extent of IBD, in
particular recognition of acute severe colitis. Knows treatment options
including aminosalicylates, corticosteroids, and steroid sparing

Knows differing methods of delivery for therapy.
Selects of appropriate treatment for extent and severity of disease,
including timing of immunomodulator therapy and referral for surgery.

Recognises the urgency of treating acutely sick patients, including
multidisciplinary team early, particularly surgeons. Clearly explains
the clinical situation and treatment options to patient and family.
Involves patient and family in decision making about treatment

Knows the complications of IBD including stricturing, fistulae,
extraintestinal manifestations, colon cancer and special situations
such as pregnancy.

Able to recognise potential complications and take appropriate action
to investigate and alter treatment as necessary including referral for
surgery and involvement of other healthcare professionals

Works with patient to explain complications and options for treatment
Involves the multidisciplinary team especially IBD nurse and surgeon
in management, and tailors treatment to the needs of the patient.
Discusses with colleagues early and appropriately



Understands the importance of multidisciplinary decision making
including when radiological histopathological and surgical opinions
should be sought

Understands the role of the IBD nurse within the MDT and in
communicating with patients and their relatives

Recognises the importance of other healthcare professionals in
providing high quality care including dieticians and pharmacists

Aware of the surgical options available in IBD and how to access

Has appropriate discussions with other specialties including
surgeons and other healthcare professionals

Can participate in an IBD MDT effectively
Relates well with all other healthcare professionals involved in IBD
patient care especially the IBD Nurse Specialist

Shows commitment to team-working and shows understanding of the
roles of other healthcare professionals with courtesy

Explains decision making process to the patient clearly and



Knows the different treatment modalities for IBD given the disease
extent activity previous history and complications

Knows the modes of delivery of different drug therapies and their
advantages and disadvantages

Recognises the importance of patient choice in deciding therapy and
in helping to ensure adherence

Understands when surgery is the most appropriate therapeutic option
and to make appropriate referrals

Demonstrates the ability to identify the possible range of appropriate
treatments for a particular patient and have an appropriate discussion
allowing the patient and doctors to come to a sensible consensus

Effectively communicates the possible treatment options and the
potential benefits complications and side effects of each



Knows the effect of active IBD drug therapy and surgery on fecundity
and pregnancy specifically issues relating to immune suppressants
biological therapy and surgery

Knows the effect of IBD and its treatment on breast feeding
Knows the effects of the disease and its treatment on the chances of
conception for men with IBD

Appreciates when to alter treatment to take account of pregnancy and
breast feeding

Can provide accurate advice about the effect of disease treatment
and surgery on fecundity pregnancy and lactation

Can discuss in an appropriate manner the treatment options for
patients wishing to conceive who are already pregnant or who wish
to breast feed

Explains the issues relating to treatment to those patients and their
partners who are planning to conceive so as to enable them to make
informed choices



Knows the risks relating to a previous history of malignancy or the
development of malignancy in IBD in particular to understand how
this affects treatment options

Knows the risks relating to infection with hepatitis B hepatitis C and
HIV connected with treatment of IBD

Knows the circumstances in which patients should be screened or
immunised for infectious diseases before commencing therapy

Can identify patients at risk for particular treatment due to concurrent
or pervious medical conditions

Can identify patients who need to be screened or immunised for
infectious diseases prior to therapy

Understands the treatment options available for patients with preexisting medical conditions

Can explain to patients the reasons for screening /immunising
Can explain the way that treatment may be affected by other medical
conditions and to start appropriate treatment

Perianal Fistulas

Simple Complex Recurrence 32% 23% 50% will need a proctectomy (esp if rectal disease) 6% will need op At 30 months Mean time to recurrence 2.8yrs (faster if rectal disease) Mean time to fistula closure 14 weeks Diagnostic Process:Locate the origin of the fistula and its anatomy .Find originating intestinal loop (inflammation or stenosis).Identify or exclude local sepsis (abscess).Determine affected organ and contribution to systemic symptoms or impairment of QOL.Assess the nutritional status. 4. CsA:Not recommended5. Tacrolimus:Cause partial closure; bad at inducing remis-sion6. Other treatments; Enteral or parenteral nutrition, mycophenolate mofetil, methotrexate, thalidomide, GCSF, and hyperbaric O2 anecdotal evidence but not recom- Classification: Intersphincteric fistulas travel along the intersphincteric plane to the perianal skin.Transsphincteric fistulas encompass a portion of the internal and external sphincter, and terminate on the skin overlying the buttock.Suprasphincteric fistulas encompass the entire sphincter apparatus.Extrasphincteric fistulas extend from an internal ope-ing in the bowel proximal to the anus, encompass the entire sphincter apparatus, and open onto the skin overlying the buttocks. Simple fistula Rectal inflammation No rectalinflammation Consider doing noth-ing (48% heal sponta-neously SurgeryFistulotomy (eg for intersphincteric or low transsphincteric)Fibrin glueIf these fail / inappropriate, treat as complex fistula Non-perianal fistulating CD: Infliximab causes closure in 45% Enterogynaecological fistulas Low anal-introital fistula may be almost asymptomatic and not need surgical treatment.If the patient has a symptomatic fistula, surgery is usually necessary (including diverting ostomy) .Enterovesical fistulas Surgery is the preferred approach for enterovesical fistulas.Recommendations for enterocutaneous fistulas Post-surgical enterocutaneous fistulas should initially be treated conservatively, with nutritional support and anatomical definition. Surgery after an interval is appropriate once nutrition is restored.Primary enterocutaneous fistulse can be treated either surgically (by resecting the diseased bowel segment) or medically. Rectovaginal Fistulas: 5-23% of CrohnsPoor prognosis if on-going rectal inflammation72% recurrnce overall at 24 months Complex fistula Anatomical position: LowExternal orifice: 1 singleFluctuation: NeverRectovaginal fistula: NeverStricture: Never Anatomical position: HghExternal orifice: MultipleFluctuation: PossibleRectovaginal fistula: PossibleStricture: Possible Suggested infliximab regime Exclude abscess with MRI and drain/ seton if needed 3 doses IFX @ 0,2,6 wks. Remove setons at 2-6wks 8wkly infusions. Review before each one If clinical response (>50% fistula closure) give further IFX dose. If no response, only continue tx if active luminal disease Post tx MRI after 4 wks If residual fistula give 2 more 8wkly infusions and repeat MRI; if healed cease IFX If still no improvement after 45 weeks tx consider thalidomide/ adalimumab; if partial improvement then further IFX for 6 months 1. Antibiotics: Metronidazole and/or ciprofloxacinRarely cause complete closureWithdrawal can cause exacerbation2. AZA/ 6MP: Effective to close and maintain closure3. InfliximabTreats simple/complex perianal fistulas, Give 5 mg/kg iv @ 0, 2, and 6wks-55% get complete closure.Closure in 35% so continue for at least 1 year Non-cutting setonDrain abscess if presentConsider diverting ostomyAntibioticsAZA/ 6MPInfliximab First line Second line Diverting ostomyProctocolec-tomy Diagnosis And Management of Fistulating CD Diagnostic methods for perianal fistulas:Proctosigmoidoscopy to rule out local inflammationPelvic MRI.EUA if MRI contraindicated or if perianal pain (almost always an abscess).Anorectal USS-accuracy of 75% esp if done with hydro-gen peroxide enhancement but technically difficult.Fistulography- not recommended. Management of non-perianal fistulating CD Written by Dr Sebastian Zeki

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