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Diagnosis and management of fistulizing Crohn's disease

Abstract

The transmural inflammation characteristic of Crohn's disease predisposes patients to the formation of fistulas. Up to 50% of patients with Crohn's disease are affected by fistulas, which is a major problem given the considerable morbidity associated with this complication. Appropriate treatment of fistulas requires knowledge of specific pharmacological and surgical therapies. Treatment options depend on the severity of symptoms, fistula location, the number and complexity of fistula tracts, and the presence of rectal complications. Internal fistulas, such as ileoileal or ileocecal fistulas, are mostly asymptomatic and do not require intervention. By contrast, perianal fistulas can be painful and abscesses may develop that require surgical drainage with or without seton placement, transient ileostomy, or in severe cases, proctectomy. This Review describes the epidemiology and pathology of fistulizing Crohn's disease. Particular focus is given to external and perianal fistulas, for which treatment options are well established. Available therapeutic options, including novel therapies, are discussed. Wherever possible, practical and evidence-based treatment regimens for Crohn's disease-associated fistulas are provided.

Key Points

  • Fistulas are a major problem for patients with Crohn's disease, and occur in up to 50% of patients

  • Treatments for fistulizing Crohn's disease have evolved greatly over the past decade, mostly as a result of the introduction of biologic therapy

  • The classification of fistulas in patients with Crohn's disease remains poorly defined and largely investigator-dependent, although MRI might provide objective information

  • A treatment algorithm for fistulizing Crohn's disease is presented; however, an optimal outcome is dependent on the use of a multidisciplinary approach

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Figure 1: MRI of a supralevatoric fistula in a patient with Crohn's disease.
Figure 2: Resected intestinal segment from a patient with Crohn's disease who had an enteroenteric fistula.
Figure 3: MRI showing an enterocutaneous fistula (arrow) in a patient with ileocolic Crohn's disease.
Figure 4: Hypothetical model of the pathophysiology of fistula formation.
Figure 5: Algorithm for the treatment of external fistulas in patients with Crohn's disease.

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Acknowledgements

The authors were supported by grants from Fonden til Lægevidenskabens Fremme (the AP Møller Foundation), the Augustinus Foundation, Aase and Ejnar Danielsens Foundation, and the Danish Research Agency, Ministry of Science, Technology and Innovation, grant #22-04-0622. Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Correspondence to Ole Haagen Nielsen.

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G Rogler has received grant/research support from Abbott and UCB Pharma. OØ Thomsen has received grant/research support from UCB Pharma. OH Nielsen and D Hahnloser declared no competing interests.

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Nielsen, O., Rogler, G., Hahnloser, D. et al. Diagnosis and management of fistulizing Crohn's disease. Nat Rev Gastroenterol Hepatol 6, 92–106 (2009). https://doi.org/10.1038/ncpgasthep1340

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