Treatment of perianal fistula and abscess: Crohn’s and non-Crohn’s

  • Houssam E. Mardini
  • David A. SchwartzEmail author

Opinion statement

The management of perianal abscesses and fistulas is relatively straightforward in most cases and based on a sound knowledge of the anatomy of the anorectum and adherence to established medical and surgical principles. Asymptomatic fistulas should not be treated, whereas abscesses require surgical drainage under general anesthesia. Fistula treatment includes drainage of any associated sepsis and eradication of the fistula track to prevent recurrence while preserving sphincter integrity. A small percentage of anal abscesses and fistulas are complex and very challenging to manage, particularly in conditions such as rectovaginal fistulas and abscesses and/or fistulas complicating Crohn’s disease. Treatment strategies in these situations rely on an accurate clinical assessment of the degree of rectal inflammation and perianal pathology. Treatment should combine aggressive medical therapy (antibiotics, immunomodulators, and anti-tumor necrosis factor antibody treatment) and minimal surgical interventions. Patients with proctitis have a significantly lower healing rate and a significantly higher complication rate with aggressive surgical interventions.


Adalimumab Main Side Effect Main Drug Interaction External Anal Sphincter Perianal Fistula 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Kaiser AM, Ortega AE: Anorectal anatomy. Surg Clin North Am 2002, 82:1125–1138.PubMedCrossRefGoogle Scholar
  2. 2.
    Rickard MJ: Anal abscesses and fistulas. ANZ J Surg 2005, 75:64–72.PubMedCrossRefGoogle Scholar
  3. 3.
    Nelson RL: Anorectal abscess fistula: what do we know? Surg Clin North Am 2002, 82:1139–1151.PubMedCrossRefGoogle Scholar
  4. 4.
    Parks AJ: Pathogenesis and treatment of fistula-in-ano. Br Med J 1961, 18:463.CrossRefGoogle Scholar
  5. 5.
    Markowitz J, Grancher K, Rosa J, et al.: Highly destructive perianal disease in children with Crohn’s disease. J Pediatr Gastroenterol Nutr 1995, 21:149–153.PubMedCrossRefGoogle Scholar
  6. 6.
    Kangas E, Hiltunen KM, Matikainen M: Anorectal function in Crohn’s disease. Ann Chir Gynaecol 1992, 81:43–47.PubMedGoogle Scholar
  7. 7.
    Wise PE, Schwartz DA: Management of perianal Crohn’s disease. Clin Gastroenterol Hepatol 2006, 4:426–430.PubMedCrossRefGoogle Scholar
  8. 8.
    Sandborn WJ, Fazio VW, Feagan BG, et al.: AGA technical review on perianal Crohn’s disease. Gastroenterology 2003, 125:1508–1530.PubMedCrossRefGoogle Scholar
  9. 9.
    Schwartz DA, Loftus EV, Jr, Tremaine WJ, et al.: The natural history of fistulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology 2002, 122:875–880.PubMedCrossRefGoogle Scholar
  10. 10.
    Makowiec F, Jehle EC, Becker HD, Starlinger M: Perianal abscess in Crohn’s disease. Dis Colon Rectum 1997, 40:443–450.PubMedCrossRefGoogle Scholar
  11. 11.
    Bell SJ, Williams AB, Wiesel P, et al.: The clinical course of fistulating Crohn’s disease. Aliment Pharmacol Ther 2003, 17:1145–1151.PubMedCrossRefGoogle Scholar
  12. 12.
    Billingham RP, Isler JT, Kimmins MH, et al.: The diagnosis and management of common anorectal disorders. Curr Probl Surg 2004, 41:586–645.PubMedGoogle Scholar
  13. 13.
    Zmora O, Tulchinsky H, Gur E, et al.: Gracilis muscle transposition for fistulas between the rectum and urethra or vagina. Dis Colon Rectum 2006, 49:1316–1321.PubMedCrossRefGoogle Scholar
  14. 14.
    Whiteford MH, Kilkenny J, 3rd, Hyman N, et al.: Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum 2005, 48:1337–1342.PubMedCrossRefGoogle Scholar
  15. 15.
    Finlay IG: Objectives in management. In Anal Fistula: Surgical Evaluation and Management. Edited by Phillips RK, Lunniss PJ. London: Chapman & Hall; 1996:69–72.Google Scholar
  16. 16.
    Bartram C, Buchanan G: Imaging anal fistula. Radiol Clin North Am 2003, 41:443–457.PubMedCrossRefGoogle Scholar
  17. 17.
    Schwartz DA, Wiersema MJ, Dudiak KM, et al.: A comparison of endoscopic ultrasound, magnetic resonance imaging, and exam under anesthesia for evaluation of Crohn’s perianal fistulas. Gastroenterology 2001, 121:1064–1072.PubMedCrossRefGoogle Scholar
  18. 18.
    Quah HM, Tang CL, Eu KW, et al.: Meta-analysis of randomized clinical trials comparing drainage alone vs primary sphincter-cutting procedures for anorectal abscess-fistula. Int J Colorectal Dis 2006, 21:602–609.PubMedCrossRefGoogle Scholar
  19. 19.
    Hull TL: Treatment options for anal fistulas. In: Benign Anorectal Diseases: Diagnosis with Endoanal and Endorectal Ultrasound and New Treatment Options, edn 1. Edited by Santoro GA, Di Falco G. New York: Springer; 2006:389–398.Google Scholar
  20. 20.
    Johnson EK, Gaw JU, Armstrong DN: Efficacy of anal fistula plug vs. fibrin glue in closure of anorectal fistulas. Dis Colon Rectum 2006, 49:371–376.PubMedCrossRefGoogle Scholar
  21. 21.
    Champagne BJ, O’Connor LM, Ferguson M, et al.: Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum 2006, 49:1817–1821.PubMedCrossRefGoogle Scholar
  22. 22.
    O’Connor L, Champagne BJ, Ferguson MA, et al.: Efficacy of anal fistula plug in closure of Crohn’s anorectal fistulas. Dis Colon Rectum 2006, 49:1569–1573.PubMedCrossRefGoogle Scholar
  23. 23.
    Present DH, Rutgeerts P, Targan S, et al.: Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 1999, 340:1398–1405.PubMedCrossRefGoogle Scholar
  24. 24.
    Sands BE, Anderson FH, Bernstein CN, et al.: Infliximab maintenance therapy for fistulizing Crohn’s disease. N Engl J Med 2004, 350:876–885.PubMedCrossRefGoogle Scholar
  25. 25.
    Regueiro M, Mardini H: Treatment of perianal fistulizing Crohn’s disease with infliximab alone or as an adjunct to exam under anesthesia with seton placement. Inflamm Bowel Dis 2003, 9:98–103.PubMedCrossRefGoogle Scholar
  26. 26.
    Hyder SA, Travis SP, Jewell DP, et al.: Fistulating anal Crohn’s disease: results of combined surgical and infliximab treatment. Dis Colon Rectum 2006, 49:1837–1841.PubMedCrossRefGoogle Scholar
  27. 27.
    Pearson DC, May GR, Fick GH, et al.: Azathioprine and 6-mercaptopurine in Crohn’s disease (a meta analysis). Ann Intern Med 1995, 123:132–142.PubMedGoogle Scholar
  28. 28.
    Kandiel A, Fraser AG, Korelitz BI, et al.: Increased risk of lymphoma among inflammatory bowel disease patients treated with azathioprine and 6-mercaptopurine. Gut 2005, 54:1121–1125.PubMedCrossRefGoogle Scholar
  29. 29.
    Lichtenstein GR, Abreu MT, Cohen R, et al.: American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology 2006, 130:940–987.PubMedCrossRefGoogle Scholar
  30. 30.
    Loftus CG, Egan LJ, Sandborn WJ: Cyclosporine, tacrolimus, and mycophenolate mofetil in the treatment of inflammatory bowel disease. Gastroenterol Clin North Am 2004, 33:141–169.PubMedCrossRefGoogle Scholar
  31. 31.
    Egan LJ, Sandborn WJ, Tremaine WJ: Clinical outcome following treatment of refractory inflammatory and fistulizing Crohn’s disease with intravenous cyclosporine. Am J Gastroenterol 1998, 93:442–448.PubMedCrossRefGoogle Scholar
  32. 32.
    Lichtenstein GR, Yan S, Bala M, et al.: Infliximab maintenance treatment reduces hospitalizations, surgeries, and procedures in fistulizing Crohn’s disease. Gastroenterology 2005, 128:862–869.PubMedCrossRefGoogle Scholar
  33. 33.
    Bodger K: Economic implications of biological therapies for Crohn’s disease: review of infliximab. Pharmacoeconomics 2005, 23:875–888.PubMedCrossRefGoogle Scholar
  34. 34.
    Siegel CA, Hur C, Korzenik JR, et al.: Risks and benefits of infliximab for the treatment of Crohn’s disease. Clin Gastroenterol Hepatol 2006, 4:1017–1024.PubMedCrossRefGoogle Scholar
  35. 35.
    Hanauer SB, Sandborn WJ, Rutgeerts P, et al.: Human antitumor necrosis factor monoclonal antibody (adalimumab) in Crohn’s disease: the CLASSIC-I trial. Gastroenterology 2006, 130:323–333.PubMedCrossRefGoogle Scholar
  36. 36.
    Colombel JF, Sandborn WJ, Rutgeerts P, et al.: Adalimumab for maintenance of clinical response and remission in patients with Crohn’s disease: the CHARM trial. Gastroenterology 2007, 132:52–65.PubMedCrossRefGoogle Scholar
  37. 37.
    Peyrin-Biroulet L, Laclotte C, Bigard MA: Adalimumab maintenance therapy for Crohn’s disease with intolerance or lost response to infliximab: an open-label study. Aliment Pharmacol Ther 2007, 25:675–680.PubMedCrossRefGoogle Scholar
  38. 38.
    Sandborn WJ, Present DJ, Isaacs KL, et al.: Tacrolimus for the treatment of fistulas in patients with Crohn’s disease (a randomized, placebo-controlled trial). Gastroenterology 2003, 125:380–388.PubMedCrossRefGoogle Scholar
  39. 39.
    Schwartz DA, White CM, Wise PE, et al.: Use of endoscopic ultrasound to guide combination medical and surgical therapy for patients with Crohn’s perianal fistulas. Inflamm Bowel Dis 2005, 11:727–732.PubMedCrossRefGoogle Scholar
  40. 40.
    Parks AG, Gordon PH, Hardcastle JD: A classification of fistula-in-ano. Br J Surg 1976, 63:1–12.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  1. 1.Inflammatory Bowel Disease CenterVanderbilt University Medical CenterNashvilleUSA

Personalised recommendations