Uni Wong, MD, on Perianal Crohn Disease

Dr Wong reviews her presentation from the Advances in Inflammatory Bowel Diseases regional meeting on caring for patients with perinanal Crohn disease.

Uni Wong, MD, is an assistant professor of medicine at the University of Maryland School of Medicine.

TRANSCRIPT:

Hi, I'm Uni Wong. I'm an assistant professor of medicine at the University of Maryland IBD Program. My talk at the AIBD Regionals was on perianal Crohn's disease today and tomorrow.

As you all know, Crohn's patients have about 40% lifetime risk of developing perianal disease. About 5% of Crohn's patients will present with isolated perianal disease. This type of phenotype within Crohn's disease can be notoriously difficult to treat.

These patients can present with skin tags, anal fissure, anal ulcer, anal stenosis, perianal fistula, and abscess. We categorized perianal fistula as either simple or complex based on location, presence of branching, number of openings to the skin, whether an abscess is present and whether other organs are involved.

The optimal treatment for perianal Crohn's disease requires a multidisciplinary team involving gastroenterology, radiology, and surgery. Pelvic MRI and endoscopic ultrasound are excellent imaging modalities. When either of these imaging modalities is combined with exam under anesthesia, the sensitivity of identifying abscess and fistula tract approaches 100%.

Once the abscess and fistula tracts are identified, drainage and seton placement is recommended in order to control local sepsis, followed by initiation of medical therapy. The setons are there to help maintain patency to all these fistula tracts to prevent recurrent abscess. If needed, the setons can remain in place permanently.

Medical therapies that are used include antibiotics, including ciprofloxacin and/or metronidazole, anti-TNF monotherapy, or combination therapy with thiopurine. Vedolizumab and ustekinumab are other biologics that have been examined for perianal Crohn's disease. Perianal Crohn's disease is in general should be monitored and reassessed 6 months after initiation of medical therapy using physical exam plus pelvic MRI or endoscopic ultrasound.

If there is ongoing inflammation identified on these imaging modalities, the seton should be left in place longer and medical therapy should be escalated. For simple fistula and patients without proctitis, surgical options include fistulotomy, ligation of intersphincteric fistula, or endorectal advancement flap.

For those with severe cases that are medically refractory, fecal diversion with or without proctectomy should be considered. Mesenchymal stem cell therapy is a relatively new treatment modality we have for perianal Crohn's treatment.

In the Mayer Crohn's study, over 200 patients were randomized in 1-to-1 fashion to adipose-derived stem cell versus placebo. They looked at the weights of closure of all treated external openings. The group who received stem cell treatment had a significantly higher rates of response and that response was maintained through week 52.

This form of treatment was very well tolerated. There were no systemic complications, no systemic infection. The most common adverse reaction was pain at the injection site, second most common being perianal abscess at the injection site at a frequency that was the same between treatment arm and placebo arm.

Thank you for your time. I hope you enjoyed the talk.