How to manage anal ulcerations and anorectal stenosis in Crohn’s disease: algorithm-based decision making

French National Working Group Consensus 2018
  • D. BouchardEmail author
  • C. Brochard
  • B. Vinson-Bonnet
  • G. Staumont
  • L. Abramowitz
  • P. Benfredj
  • N. Fathallah
  • J.-L. Faucheron
  • T. Higuero
  • Y. Panis
  • V. de Parades
  • L. Siproudhis
  • D. Laharie
  • F. Pigot
Original Article


The French National Society of Coloproctology established national recommendations for the treatment of anoperineal lesions associated with Crohn’s disease. Treatment strategies for anal ulcerations and anorectal stenosis are suggested. Recommendations have been graded following international recommendations, and when absent professional agreement was established. For each situation, practical algorithms have been drawn.


Crohn’s disease Anal ulcerations Anorectal stenosis Treatment 



Anal ulceration of Crohn’s disease


Ano-perineal lesion


Crohn’s disease


Professional agreement


Expert agreement


Nuclear magnetic resonance imaging





This work was supported by the French National Society of Coloproctology (SNFCP) and the Groupe d’Etudes Thérapeutique des Affections Inflammatoires du Tube Digestif (GETAID).

Compliance with ethical standards

Conflict of interest

Bouchard D: Abbvie, Takeda (consultant and lecture fees), Pigot F : Abbvie (lecture fees), Abramowitz L : Abbvie, Takeda (research fees), Faucheron JL : AMI, Medtronic (consultant, research fees), Laharie D : Abbvie, Janssen, MSD, Takeda (board, lectures fees), Siproudhis L : Abbvie, Ferring, MSD, Takeda (teaching sessions, consultant, research fees). The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Informed consent

For this type of study formal consent is not required.


  1. 1.
    Bouchard D, Abramowitz L, Bouguen G, Brochard C, Dabadie A, de Parades V, Eleuet-Kaplan M, Fathallah N, Faucheron J-L, Maggiori L, Panis Y, Pigot F, Roume P, Roumeguere P, Sénéjoux A, Siproudhis L, Staumont G, Suduca J-M, Vinson-Bonnet B, Zeitoun J-D (2017) Anoperineal lesions in Crohn’s disease: French recommendations for clinical practice. Tech Coloproctol 21:683–691CrossRefGoogle Scholar
  2. 2.
    Hughes LE (1992) Clinical classification of perianal Crohn’s disease. Dis Colon Rectum 35:928–932CrossRefGoogle Scholar
  3. 3.
    Schwartz DA, Loftus EV Jr, Tremaine WJ, Panaccione R, Harmsen WS, Zinsmeister AR, Sandborn WJ (2002) The natural history of fistulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology 122:875–880CrossRefGoogle Scholar
  4. 4.
    Eglinton TW, Roberts R, Pearson J et al (2012) Clinical and genetic risk factors for perianal Crohn’s disease in a population-based cohort. Am J Gastroenterol 107:589–596CrossRefGoogle Scholar
  5. 5.
    Siproudhis L, Mortaji A, Mary JY, Juguet F, Bretagne JF, Gosselin M (1997) Anal lesions: any significant prognosis in Crohn’s disease ? Eur J Gastroenterol Hepatol 9:239–243CrossRefGoogle Scholar
  6. 6.
    Horaist C, de Parades V, Abramowitz L et al (2017) Elaboration and validation of Crohn’s disease anoperineal lesions consensual definitions. World J Gastroenterol 23:5371–5378CrossRefGoogle Scholar
  7. 7.
    Travis S, Van Assche G, Dignass A, Cabré E, Gassull MA (2010) On the second ECCO Consensus on Crohn’s disease. J Crohns Colitis 4:1–6CrossRefGoogle Scholar
  8. 8.
    Vernier-Massouille G, Balde M, Salleron J, Turck D, Dupas JL, Mouterde O, Merle V, Salomez JL, Branche J, Marti R, Lerebours E, Cortot A, Gower-Rousseau C, Colombel JF (2008) Natural history of pediatric Crohn’s disease: a population-based cohort study. Gastroenterology 135:1106–1113CrossRefGoogle Scholar
  9. 9.
    Fleshner PR, Schoetz DJ Jr, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC (1995) Anal fissure in Crohn’s disease: a plea for aggressive management. Dis Colon Rectum 38:1137–1143CrossRefGoogle Scholar
  10. 10.
    D’Ugo S, Franceschilli L, Cadeddu F, Leccesi L, Blanco Gdel V, Calabrese E, Milito G, Di Lorenzo N, Gaspari AL, Sileri P (2013) Medical and surgical treatment of haemorrhoids and anal fissure in Crohn’s disease: a critical appraisal. BMC Gastroenterol 13:11 47.CrossRefGoogle Scholar
  11. 11.
    Wolkomir AF, Luchtefeld MA (1993) Surgery for symptomatic hemorrhoids and anal fissures in Crohn’s disease. Dis Colon Rectum 36:545–547CrossRefGoogle Scholar
  12. 12.
    Ouraghi A, Nieuviarts S, Mougenel JL et al (2001) Infliximab therapy for Crohn’s disease anoperineal lesions. Gastroenterol Clin Biol 25:949–956Google Scholar
  13. 13.
    Bouguen G, Trouilloud I, Siproudhis L et al (2009) Long-term outcome of non-fistulizing (ulcers, stricture) perianal Crohn’s disease in patients treated with infliximab. Aliment Pharmacol Ther 30:749–756CrossRefGoogle Scholar
  14. 14.
    Colombel JF, Sandborn WJ, Reinisch W et al (2010) SONIC Study Group. Infliximab, azathioprine, or combination therapy for Crohn’s disease. N Engl J Med 362:1383–1395CrossRefGoogle Scholar
  15. 15.
    Bouguen G, Siproudhis L, Gizard E et al (2013) Long-term outcome of perianal fistulizing Crohn’s disease treated with infliximab. Clin Gastroenterol Hepatol 11:975–81.e1-4Google Scholar
  16. 16.
    Cosnes J, Bourrier A, Laharie D et al (2013) Groupe d’Etude Thérapeutique des Affections Inflammatoires du Tube Digestif (GETAID). Early administration of azathioprine vs conventional management of Crohn’s Disease: a randomized controlled trial. Gastroenterology 145:758–765CrossRefGoogle Scholar
  17. 17.
    Palder SB, Shandling B, Bilik R, Griffiths AM, Sherman P (1991) Perianal complications of pediatric Crohn’s disease. J Pediatr Surg 26:513–515CrossRefGoogle Scholar
  18. 18.
    Ruemmele FM, Veres G, Kolho KL, European Crohn’s and Colitis Organisation, European Society of Pediatric Gastroenterology, Hepatology and Nutrition et al (2014) Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn’s disease. J Crohns Colitis 8:1179–1207CrossRefGoogle Scholar
  19. 19.
    Yamamoto T, Allan RN, Keighley MR (2000) Effect of fecal diversion alone on perianal Crohn’s disease. World J Surg 24:1258–1262CrossRefGoogle Scholar
  20. 20.
    Regimbeau JM, Panis Y, Pocard M et al (2001) Long-term results of ileal pouch-anal anastomosis for colorectal Crohn’s disease. Dis Colon Rectum 44:769–778CrossRefGoogle Scholar
  21. 21.
    Gu J, Valente MA, Remzi FH, Stocchi L (2015) Factors affecting the fate of faecal diversion in patients with perianal Crohn’s disease. Colorectal Dis 17:66–72CrossRefGoogle Scholar
  22. 22.
    Bafford AC, Latushko A, Hansraj N, Jambaulikar G, Ghazi LJ (2017) The use of temporary fecal diversion in colonic and perianal crohn’s disease does not improve outcomes. Dig Dis Sci 62:2079–2086CrossRefGoogle Scholar
  23. 23.
    Hong MK, Craig Lynch A et al (2011) Faecal diversion in the management of perianal Crohn’s disease. Colorectal Dis 13:171–176CrossRefGoogle Scholar
  24. 24.
    Singh S, Ding NS, Mathis KL, Dulai PS, Farrell AM, Pemberton JH, Hart AL, Sandborn WJ, Loftus EV Jr (2015) Systematic review with meta-analysis: faecal diversion for management of perianal Crohn’s disease. Aliment Pharmacol Ther 42:783–792CrossRefGoogle Scholar
  25. 25.
    Li W, Stocchi L, Elagili F, Kiran RP, Strong SA (2017) Healing of the perineal wound after proctectomy in Crohn’s disease patients: only preoperative perineal sepsis predicts poor outcome. Tech Coloproctol 21:715–720CrossRefGoogle Scholar
  26. 26.
    Adam S (2000 May) Perineal wound morbidity following proctectomy for inflammatory bowel disease (IBD). Colorectal Dis 2(3):165–169CrossRefGoogle Scholar
  27. 27.
    Irvine EJ (1995) Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. McMaster IBD Study Group. J Clin Gastroenterol 20:27–321CrossRefGoogle Scholar
  28. 28.
    Panes J, Bouhnik Y, Reisnish W et al, Imaging techniques for assessment of inflammatory bowel diseases: joint ECCO and ESGAR evidence based consensus guidelines. J Crohns Colitis 7:556–585Google Scholar
  29. 29.
    Linares L, Moreira LF, Andrews H, Allan RN, Alexander-Williams J, Keighley MR (1988) Natural history and treatment of anorectal strictures complicating Crohn’s disease. Br J Surg 75(7):653–655CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • D. Bouchard
    • 1
    Email author
  • C. Brochard
    • 2
  • B. Vinson-Bonnet
    • 3
  • G. Staumont
    • 4
  • L. Abramowitz
    • 5
  • P. Benfredj
    • 6
  • N. Fathallah
    • 6
  • J.-L. Faucheron
    • 7
  • T. Higuero
    • 8
  • Y. Panis
    • 9
  • V. de Parades
    • 6
  • L. Siproudhis
    • 2
  • D. Laharie
    • 10
  • F. Pigot
    • 1
  1. 1.Bagatelle HospitalTalence CedexFrance
  2. 2.University Hospital CenterRennes Cedex 9France
  3. 3.Poissy-Saint Germain en Laye HospitalPoissyFrance
  4. 4.La Croix du Sud ClinicQuint-FonsegrivesFrance
  5. 5.Ramsay Générale de Santé, Blomet ClinicParisFrance
  6. 6.Saint Joseph HospitalParisFrance
  7. 7.University Hospital Center Grenoble-AlpesLa TroncheFrance
  8. 8.BeausoleilFrance
  9. 9.Beaujon HospitalClichyFrance
  10. 10.Umniversity Hospital Center Haut LévêquePessac CedexFrance

Personalised recommendations