Dr Regueiro gives highlights of his talk at Digestive Disease Week on the challenges of perianal and fistulizing Crohn's disease and some of the options available for treatment.

Miguel Regueiro, MD, is professor of medicine and chair of the Digestive Disease Institute at Cleveland Clinic in Cleveland, Ohio. 

I'm Dr. Miguel Regueiro, chief of Digestive Disease Institute at Cleveland Clinic in Cleveland, Ohio. I'm also professor of medicine at Case Western University Cleveland Clinic Learner College of Medicine.  And I'm coming to you from DDW 2024.

One aspect and talk that I'd like to really focus on is the named lecture talk on Sunday of DDW, where we discuss challenging presentations and management decisions and inflammatory bowel disease. And I had the honor of presenting on perianal and fistulizing Crohn's disease.

And really the key take-homes from this are that we know that about 25% of patients will develop perianal fistula and this can be a very difficult disease to treat. The really 3 key take-home points are, 1, we need to work with our surgeons and the surgeons often will place setons to eliminate any infection. Two is that we do have better medical therapies, but the medical therapy really that still holds true today is infliximab, based on the 1999 study that I presented during this lecture and I'm sure many of us still use. But we also in the medical therapies know that upadacitinib has data, risankizumab, ustekinumab, vedolizumab. So I outlined some of these medication approaches.

And then thirdly, there is excitement around future development of other therapies. Now this is a bit mixed because in the United States stem cells, unfortunately in the recent trial, were negative. So we don't know that we're going to see stem cells for perianal fistula in the US, but for international colleagues they are using stem cells for fistula in Europe, different parts of Asia, and other parts of the world.

And then another part of my discussion was intra-abdominal fistula, which often presents with an abscess. Often there's a stricture. This also requires combination therapies.

The real 3 take-home points from this were, one, we need to drain any infection in the abdomen, any abscess, and this can be done radiographically. Two, medications may work, such as TNF inhibitors, if the abscess is small and it's not associated with a stricture, which means we can heal the abscess with antibiotics or drain it without surgery, then go on a medication. But then really, third is that some of the larger abscesses, and I end my talk with an algorithm that really looks at the larger abscesses, and those are the ones that we need to drain, but in my opinion really needs surgery, a surgical resection either with an ostomy or without an ostomy.

So I hope that that was helpful in terms of discussing fistulizing Crohn's disease and the key aspects that I presented at DDW 2024.