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Perianal magnetic resonance imaging findings and their potential impact on outcome in children with perianal fistulizing Crohn disease

Pediatric Radiology volume 51, pages 2481–2491 (2021)Cite this article

Abstract

Background

Children with perianal fistulizing Crohn disease require intensive medical management but also have a higher risk for subsequent surgical interventions.

Objective

We performed a retrospective study to identify patient factors and perianal anatomical features by pelvic MR that are associated with surgical interventions in these children.

Materials and methods

We included children with Crohn disease and perianal fistula who underwent pelvic MR with available, archived images and collected demographic, clinical and laboratory data. Radiologists reviewed pelvic MR exams and identified Park classification and additional anatomical features of perianal fistulas, including fistula branching, horseshoe ramifications, abscess, inflammatory mass, supralevator extension, anal sphincter damage, proctitis and posterior anal space involvement. We performed univariate and subsequent multivariate analysis to determine features associated with subsequent surgical intervention.

Results

Ninety-nine children with Crohn disease underwent pelvic MR. In this cohort, 69 children had no surgical interventions prior to baseline MRI, with subsequent median clinical follow-up of 5.5 years. Univariate analysis demonstrated that branching (P=0.009), supralevator extension (P=0.015) and anal sphincter damage (P=0.031) were significantly associated with subsequent surgical intervention. Age at baseline MRI was also associated with intervention (hazard ratio [HR] every 5 years: 2.13; 95% confidence interval [CI]: 1.18–3.83; P=0.012). A multivariable model identified only fistula branching (HR: 2.31; 95% CI: 1.28–4.15; P=0.005) and age (HR: 5.18; CI: 1.57–17.14; P=0.007) as independent predictors of subsequent surgery. No demographic, clinical or laboratory parameter predicted subsequent surgical intervention.

Conclusion

Age and anatomical MR features indicating fistula complexity (branching, supralevator extension) and sphincter damage confer a higher risk of subsequent surgical intervention in children with perianal Crohn disease.

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References

  1. Maloy KJ, Powrie F (2011) Intestinal homeostasis and its breakdown in inflammatory bowel disease. Nature 474:298–306

    CAS  Article  Google Scholar 

  2. Molodecky NA, Soon IS, Rabi DM et al (2012) Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology 142:46–54.e42

    Article  Google Scholar 

  3. Benchimol EI, Fortinsky KJ, Gozdyra P et al (2011) Epidemiology of pediatric inflammatory bowel disease: a systematic review of international trends. Inflamm Bowel Dis 17:423–439

    Article  Google Scholar 

  4. Kammermeier J, Morris M, Garrick V et al (2016) Management of Crohn’s disease. Arch Dis Child 101:475–480

    Article  Google Scholar 

  5. Abramson O, Durant M, Mow W et al (2010) Incidence, prevalence, and time trends of pediatric inflammatory bowel disease in northern California, 1996 to 2006. J Pediatr 157:233–239.e1

    Article  Google Scholar 

  6. Adamiak T, Walkiewicz-Jedrzejczak D, Fish D et al (2013) Incidence, clinical characteristics, and natural history of pediatric IBD in Wisconsin: a population-based epidemiological study. Inflamm Bowel Dis 19:1218–1223

    Article  Google Scholar 

  7. Cosnes J, Cattan S, Blain A et al (2002) Long-term evolution of disease behavior of Crohn’s disease. Inflamm Bowel Dis 8:244–250

    Article  Google Scholar 

  8. Gecse KB, Sebastian S, Hertogh GD et al (2016) Results of the fifth scientific workshop of the ECCO [II]: clinical aspects of perianal fistulising Crohn’s disease — the unmet needs. J Crohns Colitis 10:758–765

    Article  Google Scholar 

  9. Bernstein CN, Loftus EV, Ng SC et al (2012) Hospitalisations and surgery in Crohn’s disease. Gut 61:622–629

    Article  Google Scholar 

  10. Tang LY, Rawsthorne P, Bernstein CN (2006) Are perineal and luminal fistulas associated in Crohn’s disease? A population-based study. Clin Gastroenterol Hepatol 4:1130–1134

    Article  Google Scholar 

  11. Eglinton TW, Barclay ML, Gearry RB, Frizelle FA (2012) The spectrum of perianal Crohn’s disease in a population-based cohort. Dis Colon rectum 55:773–777

    Article  Google Scholar 

  12. Scharl M, Rogler G, Biedermann L (2017) Fistulizing Crohn’s disease. Clin Transl Gastroenterol 8:e106

    CAS  Article  Google Scholar 

  13. Schwartz DA, Loftus EV, Tremaine WJ et al (2002) The natural history of fistulizing Crohn’s disease in Olmsted County, Minnesota. Gastroenterology 122:875–880

    Article  Google Scholar 

  14. Compton G, Bartlett M (2014) Perianal disease in pediatric Crohn disease: a review of MRI findings. Pediatr Radiol 44:1198–1208

    Article  Google Scholar 

  15. Horsthuis K, Stoker J (2004) MRI of perianal Crohn’s disease. AJR Am J Roentgenol 183:1309–1315

    Article  Google Scholar 

  16. Siegmund B, Feakins RM, Bamias G et al (2016) Results of the fifth scientific workshop of the ECCO (II): pathophysiology of perianal fistulizing disease. J Crohns Colitis 10:377–386

    Article  Google Scholar 

  17. von Lampe B, Barthel B, Coupland SE et al (2000) Differential expression of matrix metalloproteinases and their tissue inhibitors in colon mucosa of patients with inflammatory bowel disease. Gut 47:63–73

    Article  Google Scholar 

  18. Sachar DB, Bodian CA, Goldstein ES et al (2005) Is perianal Crohn’s disease associated with intestinal fistulization? Am J Gastroenterol 100:1547–1549

    Article  Google Scholar 

  19. Armuzzi A, Ahmad T, Ling K et al (2003) Genotype-phenotype analysis of the Crohn’s disease susceptibility haplotype on chromosome 5q31. Gut 52:1133–1139

    CAS  Article  Google Scholar 

  20. Vermeire S, Pierik M, Hlavaty T et al (2005) Association of organic cation transporter risk haplotype with perianal penetrating Crohn’s disease but not with susceptibility to IBD. Gastroenterology 129:1845–1853

    CAS  Article  Google Scholar 

  21. Sordo-Mejia R, Gaertner WB (2014) Multidisciplinary and evidence-based management of fistulizing perianal Crohn’s disease. World J Gastrointest Pathophysiol 5:239–251

    Article  Google Scholar 

  22. Gecse KB, Bemelman W, Kamm MA et al (2014) A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn’s disease. Gut 63:1381–1392

    Article  Google Scholar 

  23. Sheedy SP, Bruining DH, Dozois EJ et al (2017) MR imaging of perianal Crohn disease. Radiology 282:628–645

    Article  Google Scholar 

  24. de Miguel CJ, del Salto LG, Rivas PF et al (2012) MR imaging evaluation of perianal fistulas: spectrum of imaging features. Radiographics 32:175–194

    Article  Google Scholar 

  25. Parks AG, Gordon PH, Hardcastle JD (1976) A classification of fistula-in-ano. Br J Surg 63:1–12

  26. American Gastroenterological Association Clinical Practice Committee (2003) American Gastroenterological Association medical position statement: perianal Crohn’s disease. Gastroenterology 125:1503–1507

    Article  Google Scholar 

  27. Spencer JA, Chapple K, Wilson D et al (1998) Outcome after surgery for perianal fistula: predictive value of MR imaging. AJR Am J Roentgenol 171:403–406

    CAS  Article  Google Scholar 

  28. Hindryckx P, Jairath V, Zou G et al (2019) Development and validation of a magnetic resonance index for assessing fistulas in patients with Crohn’s disease. Gastroenterology 157:1233–1244.e5

    CAS  Article  Google Scholar 

  29. Samaan MA, Puylaert CAJ, Levesque BG et al (2017) The development of a magnetic resonance imaging index for fistulising Crohn’s disease. Aliment Pharmacol Ther 46:516–528

    CAS  Article  Google Scholar 

  30. Maccioni F, Bencardino D, Buonocore V et al (2019) MRI reveals different Crohn’s disease phenotypes in children and adults. Eur Radiol 29:5082–5092

    Article  Google Scholar 

  31. Hyams JS, Ferry GD, Mandel FS et al (1991) Development and validation of a Pediatric Crohn’s Disease Activity Index. J Pediatr Gastroenterol Nutr 12:439–447

  32. Hyams J, Markowitz J, Otley A et al (2005) Evaluation of the Pediatric Crohn Disease Activity Index: a prospective multicenter experience. J Pediatr Gastroenterol Nutr 41:416–421

  33. Gallego JC, Echarri A (2018) Role of magnetic resonance imaging in the management of perianal Crohn’s disease. Insights Imaging 9:47–58

    Article  Google Scholar 

  34. Halligan S, Tolan D, Amitai MM et al (2020) ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis. Eur Radiol 30:4734–4740

    CAS  Article  Google Scholar 

  35. Samaan MA, Puylaert CAJ, Levesque BG et al (2017) The development of a magnetic resonance imaging index for fistulising Crohn's disease. Aliment Pharmacol Ther 46:516–528

    CAS  Article  Google Scholar 

  36. Maccioni F, Bencardino D, Buonocore V et al (2019) MRI reveals different Crohn’s disease phenotypes in children and adults. Eur Radiol 29:5082–5092

    Article  Google Scholar 

  37. Kim HJ, Oh SH, Kim DY et al (2017) Clinical characteristics and long-term outcomes of paediatric Crohn’s disease: a single-centre experience. J Crohns Colitis 11:157–164

    Article  Google Scholar 

  38. Guizzetti L, Zou G, Khanna R et al (2018) Development of clinical prediction models for surgery and complications in Crohn’s disease. J Crohns Colitis 12:167–177

    Article  Google Scholar 

  39. Shenoy-Bhangle A, Nimkin K, Goldner D et al (2014) MRI predictors of treatment response for perianal fistulizing Crohn disease in children and young adults. Pediatr Radiol 44:23–29

    Article  Google Scholar 

  40. Mei Z, Wang Q, Zhang Y et al (2019) Risk factors for recurrence after anal fistula surgery: a meta-analysis. Int J Surg 69:153–164

    Article  Google Scholar 

  41. Lightner AL, Faubion WA (2017) Mesenchymal stem cell injections for the treatment of perianal Crohn’s disease: what we have accomplished and what we still need to do. J Crohns Colitis 11:1267–1276

    Article  Google Scholar 

  42. Lightner AL, Wang Z, Zubair AC, Dozois EJ (2018) A systematic review and meta-analysis of mesenchymal stem cell injections for the treatment of perianal Crohn’s disease: progress made and future directions. Dis Colon rectum 61:629–640

    Article  Google Scholar 

  43. Kim PH, Park SH, Jin K et al (2020) Supplementary anal imaging by magnetic resonance enterography in patients with Crohn’s disease not suspected of having perianal fistulas. Clin Gastroenterol Hepatol 18:415–423.e4

    Article  Google Scholar 

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Authors and Affiliations

  1. Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine at Peoria, Children’s Hospital of Illinois, 530 NE Glen Oak Ave., Peoria, IL, 61637, USA

    Muhammad Rehan Khan

  2. Department of Pediatrics & Child Health, Aga Khan University, Karachi, Pakistan

    Muhammad Rehan Khan

  3. Department of Pediatrics, Mayo Clinic, Rochester, MN, USA

    Jessica A. Ulrich

  4. Department of Radiology, Mayo Clinic, Rochester, MN, USA

    Nathan C. Hull, Akitoshi Inoue & Joel G. Fletcher

  5. Department of Biomedical Statistics and informatics, Mayo Clinic, Rochester, MN, USA

    William S. Harmsen

  6. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA

    William A. Faubion Jr. & Imad Absah

  7. Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA

    Imad Absah

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  1. Muhammad Rehan Khan
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  2. Jessica A. Ulrich
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  3. Nathan C. Hull
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Correspondence to Muhammad Rehan Khan.

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Conflicts of interest

Dr. Fletcher is a consultant for Takeda, GlaxoSmithKline, Janssen and Boehringer Ingelheim, with funds paid to his institution. He has received grants to his instituion from the Helmsley Charitable Trust, Siemens Healthineers, Takeda and Pfizer.

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Khan, M.R., Ulrich, J.A., Hull, N.C. et al. Perianal magnetic resonance imaging findings and their potential impact on outcome in children with perianal fistulizing Crohn disease. Pediatr Radiol 51, 2481–2491 (2021). https://doi.org/10.1007/s00247-021-05158-w

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  • DOI: https://doi.org/10.1007/s00247-021-05158-w

Keywords

  • Children
  • Crohn disease
  • Inflammatory bowel disease
  • Magnetic resonance imaging
  • Park classification
  • Perianal fistula