Current Treatment Options in Gastroenterology

, Volume 6, Issue 5, pp 391–402 | Cite as

Treatment of fistulizing Crohn’s disease in children

  • Alka Goyal
  • Evan P. Nadler
  • Henri R. Ford
  • David J. Keljo

Opinion statement

Patients with Crohn’s disease are at risk for developing both internal and external fistulae. These can be asymptomatic incidental radiologic findings or causes of incontinence, chronic pain, abscesses, and sepsis. They can have a devastating impact on quality of life. Careful prospective studies of therapy are few in adult medicine and entirely lacking in the pediatric age group. Assessment and management require a coordinated effort between gastroenterologist, radiologist, and surgeon. Principles of management include surgical drainage of infection combined with medical therapy. Only infliximab has been studied in prospective, double-blinded fashion and clearly shown to be of use in the short term. There is good evidence that metronidazole may be useful acutely and that 6-mercaptopurine azathioprine may help to maintain closure. Diverting ostomies are of very limited value and corticosteroids seem to make matters worse. There are many other therapies that have been reported to be helpful in small, uncontrolled studies.


Infliximab Main Side Effect Main Drug Interaction Anal Fistula Rectovaginal 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.
    Loftus EV Jr, Crowson CS, Sandborn WJ, et al.: Crohn’s disease in Olmsted County, Minnesota, 1940–1993: incidence, prevalence, and survival. Gastroenterology 1998, 114:1161–1168.PubMedCrossRefGoogle Scholar
  2. 2.
    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
  3. 3.
    Steinhardt HJ, et al., European Cooperative Crohn’s Disease Study (ECCDS): clinical features and natural history. Digestion 1985, 31:97–108.PubMedCrossRefGoogle Scholar
  4. 4.
    Lockhart-Mummery HE: Crohn’s disease: anal lesions. Dis Colon Rectum 1975, 18:200–202.PubMedCrossRefGoogle Scholar
  5. 5.
    Griffiths AM, Buller HB: Inflammatory bowel disease. In Pediatric Gastrointestinal Diseases, edn 3. Edited by Walker WA. Hamilton, Ontario: BC Decker; 2000:613–652.Google Scholar
  6. 6.
    Lichtenstein GR: Treatment of fistulizing Crohn’s disease. Gastroenterology 2000, 119:1132–1147. A comprehensive review on the treatment of fistulizing Crohn’s disease.PubMedCrossRefGoogle Scholar
  7. 7.
    Schwartz DA, Pemberton JH, Sandborn WJ: Diagnosis and treatment of perianal fistulas in Crohn disease. Ann Intern Med 2001, 135:906–918. A comprehensive review on treatment and diagnosis of perianal fistulae in Crohn’s disease.PubMedGoogle Scholar
  8. 8.
    Parks AG, Gordon PH, Hardcastle JD: A classification of fistula-in-ano. Br J Surg 1976, 63:1–12.PubMedCrossRefGoogle Scholar
  9. 9.
    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. A meticulous study comparing different diagnostic modalities in the work-up of fistulizing Crohn’s disease.PubMedCrossRefGoogle Scholar
  10. 10.
    Beets-Tan RG, Beets GL, van der Hoop AG, et al.: Preoperative MR imaging of anal fistulas: does it really help the surgeon? Radiology 2001, 218:75–84.PubMedGoogle Scholar
  11. 11.
    Stewart LK, McGee J, Wilson SR: Transperineal and transvaginal sonography of perianal inflammatory disease. Am J Radiol 2001, 177:627–632.Google Scholar
  12. 12.
    Best WR, Becktel JM, Singleton JW, Kern F Jr, et al.: Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study. Gastroenterology 1976, 70:439–444.PubMedGoogle Scholar
  13. 13.
    Irvine EJ: Usual therapy improves perianal Crohn’s disease as measured by a new disease activity index. McMaster IBD Study Group. J Clin Gastroenterol 1995, 20:27–32.PubMedCrossRefGoogle Scholar
  14. 14.
    Sohn N, Korelitz BI, Weinstein MA: Anorectal Crohn’s disease: definitive surgery for fistulas and recurrent abscesses. Am J Surg 1980, 139:394–397.PubMedCrossRefGoogle Scholar
  15. 15.
    Nordgren S, Fasth S, Hulten L: Anal fistulas in Crohn’s disease: incidence and outcome of surgical treatment. Int J Colorectal Dis 1992, 7:214–218.PubMedCrossRefGoogle Scholar
  16. 16.
    Fuhrman GM, Larach SW: Experience with perirectal fistulas in patients with Crohn’s disease. Dis Colon Rectum 1989, 32:847–848.PubMedCrossRefGoogle Scholar
  17. 17.
    Takesue Y, Ohge H, Yokoyama T, et al.: Long-term results of seton drainage on complex anal fistulae in patients with Crohn’s disease. J Gastroenterol 2002, 37:912–915.PubMedCrossRefGoogle Scholar
  18. 18.
    Faucheron JL, Saint-Marc O, Guibert L, et al.: Long-term seton drainage for high anal fistulas in Crohn’s disease —a sphincter-saving operation? Dis Colon Rectum, 1996, 39:208–211.PubMedCrossRefGoogle Scholar
  19. 19.
    Present DH, Korelitz BI, Wisch N, et al.: Treatment of Crohn’s disease with 6-mercaptopurine. A long-term, randomized, double-blind study. N Engl J Med 1980, 302:981–987.PubMedCrossRefGoogle Scholar
  20. 20.
    Korelitz BI, Present DH: Favorable effect of 6-mercaptopurine on fistulae of Crohn’s disease. Dig Dis Sci 1985, 30:58–64.PubMedCrossRefGoogle Scholar
  21. 21.
    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
  22. 22.
    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
  23. 23.
    Yamamoto T, Keighley MR: Enterovesical fistulas complicating Crohn’s disease: clinicopathological features and management. Int J Colorectal Dis 2000, 15:211–215;discussion 216–217.PubMedCrossRefGoogle Scholar
  24. 24.
    Gruner JS, Sehon JK, Johnson LW: Diagnosis and management of enterovesical fistulas in patients with Crohn’s disease. Am Surg 2002, 68:714–719.PubMedGoogle Scholar
  25. 25.
    Solem CA, Loftus EV Jr, Tremaine WJ, et al.: Fistulas to the urinary system in Crohn’s disease: clinical features and outcomes. Am J Gastroenterol 2002, 97:2300–2305.PubMedCrossRefGoogle Scholar
  26. 26.
    Present DH: Urinary tract fistulas in Crohn’s disease: surgery versus medical therapy. Am J Gastroenterol 2002, 97:2165–2167.PubMedCrossRefGoogle Scholar
  27. 27.
    Broe PJ, Bayless TM, Cameron JL: Crohn’s disease: are enteroenteral fistulas an indication for surgery? Surgery 1982, 91:249–253.PubMedGoogle Scholar
  28. 28.
    Simoneaux SF, Patrick LE: Genitourinary complications of Crohn’s disease in pediatric patients. Am J Roentgenol 1997, 169:197–199.Google Scholar
  29. 29.
    Bernstein LH, Frank MS, Brandt LJ, et al.: Healing of perineal Crohn’s disease with metronidazole. Gastroenterology 1980, 79:357–365.PubMedGoogle Scholar
  30. 30.
    Brandt LJ, Bernstein LH, Boley SJ, Frank MS, et al.: Metronidazole therapy for perineal Crohn’s disease: a follow-up study. Gastroenterology 1982, 83:383–387.PubMedGoogle Scholar
  31. 31.
    Turunen U, Farkkila M, Seppala K: Long-term treatment of perianal or fistulous crohn’s disease with ciprofloxacin. Scand J Gastroenterol 1989, 24(suppl 148):144.Google Scholar
  32. 32.
    O’Brien JJ, Bayless TM, Bayless JA: Use of azathioprine or 6-mercaptopurine in the treatment of Crohn’s disease. Gastroenterology 1991, 101:39–46.PubMedGoogle Scholar
  33. 33.
    Muhadevan UJ, Marion R, Present DH: The place of methotrexate in the treatment of refractory Crohn’s disease. Gastroenterology 1997, 112:A2031.Google Scholar
  34. 34.
    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
  35. 35.
    Lowry PW, Weaver AL, Tremaine WJ, et al.: Combination therapy with oral tacrolimus (FK506) and azathioprine or 6-mercaptopurine for treatment-refractory Crohn’s disease perianal fistulae. Inflamm Bowel Dis 1999, 5:239–245.PubMedCrossRefGoogle Scholar
  36. 36.
    Sandborn WJ: Preliminary report on the use of oral tacrolimus (FK506) in the treatment of complicated proximal small bowel and fistulizing Crohn’s disease. Am J Gastroenterol 1997, 92:876–879.PubMedGoogle Scholar
  37. 37.
    Present DH: Review article: the efficacy of infliximab in Crohn’s disease-healing of fistulae. Aliment Pharmacol Ther 1999, 13(suppl4):23–28; discussion 38.PubMedCrossRefGoogle Scholar
  38. 38.
    Sandborn WJ, Hanauer SB: Infliximab in the treatment of Crohn’s disease: a user’s guide for clinicians. Am J Gastroenterol 2002, 97:2962–2972.PubMedCrossRefGoogle Scholar
  39. 39.
    Stephens MC, Shepanski MA, Mamula P, et al.: Safety and steroid-sparing experience using infliximab for Crohn’s disease at a pediatric inflammatory bowel disease center. Am J Gastroenterol 2003, 98:104–111.PubMedCrossRefGoogle Scholar
  40. 40.
    Fickert P, Hinterleitner TA, Wenzl HH, et al.: Mycophenolate mofetil in patients with Crohn’s disease. Am J Gastroenterol 1998, 93:2529–2532.PubMedCrossRefGoogle Scholar
  41. 41.
    Ehrenpreis ED, Dassopoulos T, Ehrenpreis ED, et al.: Thalidomide therapy for patients with refractory Crohn’s disease: an open-label trial. Gastroenterology 1999, 117:1271–1277.PubMedCrossRefGoogle Scholar
  42. 42.
    Lavy A, Weisz G, Adir Y, et al.: Hyperbaric oxygen for perianal Crohn’s disease. J Clin Gastroenterol 1994, 19:202–205.PubMedCrossRefGoogle Scholar
  43. 43.
    Abel ME, Chiu YS, Russell TR, et al.: Autologous fibrin glue in the treatment of rectovaginal and complex fistulas. Dis Colon Rectum 1993, 36:447–449.PubMedCrossRefGoogle Scholar
  44. 44.
    Sandborn WJ: A randomized controlled trial of CDP571, a humanized antibody to TNF-a, in moderately to severe active Crohn’s disease. Gastroenterology 2000, 118:A655.CrossRefGoogle Scholar
  45. 45.
    von Andrian UH, Engelhardt B: Alpha4 integrins as therapeutic targets in autoimmune disease. N Engl J Med 2003, 348:68–72.CrossRefGoogle Scholar
  46. 46.
    Ghosh S, Goldin E, Gordon FH, et al.: Natalizumab for active Crohn’s disease. N Engl J Med 2003, 348:24–32.PubMedCrossRefGoogle Scholar
  47. 47.
    Vaughan D, Drumm B: Treatment of fistulae with granulocyte colony-stimulating factor in a patient with Crohn’s disease. N Engl J Med 1999, 340:239–240.PubMedCrossRefGoogle Scholar
  48. 48.
    Practice parameters for treatment of fistula-in-anosupporting documentation. The Standards Practice Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1996, 39:1363–1372.Google Scholar

Copyright information

© Current Science Inc 2003

Authors and Affiliations

  • Alka Goyal
    • 1
  • Evan P. Nadler
    • 1
  • Henri R. Ford
    • 1
  • David J. Keljo
    • 1
  1. 1.Departments of Gastroenterology and SurgeryChildren’s Hospital of PittsburghPittsburghUSA

Personalised recommendations