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Clinical and magnetic resonance imaging spectrum of complex perianal fistulizing Crohn’s disease: A cohort study from northern India

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Abstract

Background

Fistulizing perianal Crohn’s disease (CD) is a debilitating condition associated with significant morbidity and reduction in the quality of life. Magnetic resonance imaging (MRI) of the pelvis is the preferred imaging modality for the comprehensive assessment of the perianal fistula. There is a paucity of data from India on the MRI spectrum of complex perianal fistula in CD.

Methods

A single-centre cross-sectional analysis of patients with fistulizing perianal CD, who underwent pelvic MRI between January 2020 and December 2021, was performed. The clinical (age, sex, disease duration, disease location and behavior, disease activity [Perianal Disease Activity Index, PDAI] and treatment received) and radiological (number and location of fistulae, extensions, number and location of internal and external openings, fistula activity, presence or absence of perianal abscess and associated proctitis) characteristics of complex perianal fistula (defined according to the American Gastroenterological Association classification) were recorded.

Results

Of total 175 patients with CD who attended the gastroenterology clinic during the study period, 27 (15.42%) (mean age 42±15.5 years, 62.96% females and median disease duration four years) had complex perianal fistula and were included in the analysis. The mean PDAI was 5.48±2.53. The median Van Assche Index was 17 (interquartile range [IQR] 13–19). A majority (96.29%) of the fistulae were trans-sphincteric and four (14.81%) fistulae extended into the supralevator space. All fistulae were active on MRI. Concomitant perianal abscess and proctitis were seen in 59.26% (n=16) and 62.96% (n=17) of patients, respectively. Combination therapy with biologics and antibiotics/immune-suppressants were the most commonly prescribed medical therapy. Six (22.22%) patients underwent combined medical and surgical (non-cutting seton, fistulectomy, fecal diversion) treatment.

Conclusion

The cumulative risk of the development of fistulizing perianal CD in a northern Indian cohort was similar to the western populations. Complex perianal fistulae were predominantly trans-sphincteric and commoner in females. MRI evaluation is pivotal for the delineation of fistula anatomy, assessment of disease extent and activity and the evaluation of concomitant perianal abscess and other complications.

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Author notes

  1. Arshdeep Singh and Chandan Kakkar contributed equally and share the first authorship.

Authors and Affiliations

  1. Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, 141 001, India

    Arshdeep Singh, Ramit Mahajan, Dharmatma Singh & Ajit Sood

  2. Department of Radiology and Radiodiagnosis, Dayanand Medical College, Ludhiana, 141 001, India

    Chandan Kakkar, Ritu Dhawan Galhotra & Kavita Saggar

  3. Department of Internal Medicine, Dayanand Medical College, Ludhiana, 141 001, India

    Shreya Garg, Kirti Arora, Vandana Midha, Narender Pal Jain, Ashish Tripathi, Dhruv Gupta & Ishita Gupta Kaushal

  4. Department of Gastroenterology Surgery, Dayanand Medical College, Ludhiana, 141 001, India

    Satpal Singh Virk

  5. Department of Pediatrics, Government Medical College and Rajindra Hospital, Patiala, 147 001, India

    Kriti Sood

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  1. Arshdeep Singh
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Contributions

Arshdeep Singh: conceptualization, methodology, validation, formal analysis, investigation, resources, data curation, writing—original draft, writing—review and editing, visualization. Chandan Kakkar: methodology, validation, formal analysis, investigation, resources, data curation, writing—original draft, writing—review and editing, visualization, supervision. Shreya Garg: resources, data curation, writing—review and editing, visualization. Kirti Arora: resources, data curation, writing—review and editing. Vandana Midha: resources, data curation, writing—review and editing, visualization, supervision. Ramit Mahajan: resources, data curation, writing—review and editing, visualization, supervision. Satpal Singh Virk: resources, data curation, writing—review and editing, visualization, supervision. Narender Pal Jain: resources, writing—review and editing, visualization. Dharmatma Singh: data curation, writing—review and editing. Kriti Sood: resources, writing—review and editing, visualization. Ashish Tripathi: data curation, writing—review and editing, visualization. Dhruv Gupta: data curation, writing—review and editing. Ishita Gupta Kaushal: writing—review and editing. Ritu Dhawan Galhotra: writing—review and editing, visualization, supervision. Kavita Saggar: writing—review and editing, visualization, supervision. Ajit Sood: conceptualization, methodology, validation, formal analysis, investigation, resources, data curation, writing—review and editing, visualization, supervision.

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Correspondence to Ajit Sood.

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Conflict of interest

Ajit Sood reports receiving speaker honorarium from Pfizer India. AS, CK, SG, KA, VM, RM, SSV, NPJ, DS, KS, AT, DG, IGK, RDG and KS declare no conflict of interest.

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The study was performed conforming to the Helsinki Declaration of 1975, as revised in 2000 and 2008 concerning human and animal rights, and the authors followed the policy concerning informed consent as shown on Springer.com.

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The study was approved by the Institutional Review Board (IRB No. DMCH/R&D/2020/23). All authors had access to the study data and reviewed and approved the final manuscript.

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Singh, A., Kakkar, C., Garg, S. et al. Clinical and magnetic resonance imaging spectrum of complex perianal fistulizing Crohn’s disease: A cohort study from northern India. Indian J Gastroenterol 42, 668–676 (2023). https://doi.org/10.1007/s12664-023-01399-9

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