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Diagnosis and Treatment of Perianal Fistulas in Crohn Disease

David A. Schwartz, MD; John H. Pemberton, MD; and William J. Sandborn, MD
[+] Article and Author Information

From the Mayo Clinic, Rochester, Minnesota.


Requests for Single Reprints: William J. Sandborn, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail, sandborn.william@mayo.edu.

Current Author Addresses: Drs. Schwartz, Pemberton, and Sandborn: Mayo Clinic, 200 First Street SW, Rochester, MN 55905.


Ann Intern Med. 2001;135(10):906-918. doi:10.7326/0003-4819-135-10-200111200-00011
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Perianal fistulas occur in up to 43% of patients with Crohn disease. Diagnostic evaluation to determine the location and type of fistulas and the presence or absence of rectal inflammation is required. A combined medical and surgical approach to the management of such patients is the optimal treatment plan. Perianal abscesses must be drained. Superficial, low transsphincteric, and low intersphincteric fistulas are usually treated with fistulotomy and antibiotics. High transsphincteric, suprasphincteric, and extrasphincteric fistulas are usually treated with noncutting setons, antibiotics, and azathioprine or 6-mercaptopurine and, in many cases, infliximab.

Figures

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Figure 1.
Anatomic relationships in the perianal region.

Modified with permission from: Fry RD, Kodner IJ. Anorectal disorders. Clin Symp. 1985; 37:2-32. Modified figure copyright 2000, Mayo Clinic.

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Figure 2.
The classification system of Parks and colleagues.

A. A superficial fistula tracks below both the internal anal sphincter and external anal sphincter complexes. B. An intersphincteric fistula tracks between the internal anal sphincter and the external anal sphincter in the intersphincteric space. C. A transsphincteric fistula tracks from the intersphincteric space through the external anal sphincter. D. A suprasphincteric fistula leaves the intersphincteric space over the top of the puborectalis and penetrates the levator muscle before tracking down to the skin. E. An extrasphincteric fistula tracks outside of the external anal sphincter and penetrates the levator muscle into the rectum. Modified with permission from reference 19. Modified figure copyright 2000, Mayo Clinic.

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Figure 3.
Surgical approach to perianal abscess drainage.

A. Simple incision and drainage procedure for an abscess. B. Incision and drainage followed by placement of a mushroom drainage catheter for an abscess. Copyright 2000, Mayo Clinic.

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Figure 4.
Placement of a noncutting seton.

A noncutting seton is a suture or drain that is threaded into the cutaneous orifice of a perianal fistula, through the fistula tract, across the mucosal orifice of the fistula into the rectum, and through the rectum across the anus, where the two ends of the suture or drain are loosely tied. Copyright 2000, Mayo Clinic.

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Figure 5.
Fistulotomy.

In the absence of active proctocolitis, simple low trans-sphincteric, intersphincteric, and superficial fistulas can be treated with a fistulotomy. Copyright 2000, Mayo Clinic.

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Figure 6.
Endorectal advancement flap.

A. The fistula tract is probed to identify the internal opening of the fistula. B. The internal opening of the fistula tract is incised. C. A flap of tissue (including mucosa, submucosa, and circular muscle) around the site of the resected internal opening of the fistula is incised. D. The flap is pulled down to cover the site of the resected internal opening of the fistula. Copyright 2000, Mayo Clinic.

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Grahic Jump Location
Figure 7.
Treatment algorithm for perianal Crohn disease.

If the fistula is simple, endorectal advancement flap (asterisk) or fistulotomy () can be considered. Use of infliximab should be favored if the fistula is complex, recurrent, or associated with active rectal inflammation (). 6-MP = 6-mercaptopurine; AZA = azathioprine; EUS = endoscopic ultrasonography; MRI = magnetic resonance imaging.

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