Crohn Anorectal Disease



Crohn Anorectal Disease


James Church



Perioperative Considerations



  • The principles of the management of perianal symptoms in patients with Crohn disease



    • Define the status of the proximal bowel.



      • Colonoscopy


      • Esophagogastroduodenoscopy


      • Magnetic resolution enterography (MRE)/Computed tomography enterography (CTE)


      • ± Small bowel follow-through (MRE/CTE preferred)


    • Is there active Crohn disease? If there is, it needs to be managed either medically or surgically. Medical treatment will often help perineal Crohn disease (Crohn disease within the tissues of the perineum).


    • Has the patient had bowel resections?



      • If so, do they have diarrhea as a result and does this make them prone to incontinence? This will exacerbate perianal symptoms.


      • Use of agents to slow motility, and/or bulk formers, may help.


  • Define the status of the anal sphincters.



    • What is the status of the anal sphincters? Has there been previous surgery? Childbirth?



      • If anal ultrasound is available, this is worth adding to the assessment.


      • A thin perineum in a woman will not support flap repair of anterior fistulas (including rectovaginal fistulas) and is an indication for one of the following: perineoplasty, Martius flap, and gracilis flap.


  • Is there sepsis? If so, control it.



    • This will usually need an examination under anesthesia (EUA) to fully and completely assess the low rectum, anus, and the perineum.


    • During this examination, carefully check the perianal skin for fluctuance or asymmetry.



      • If there is a swelling, it can be aspirated; and if pus is obtained, the collection is incised and drained.


      • Openings that are already draining can be gently probed, but remember that hidradenitis is associated with perianal Crohn disease and an opening in the perianal skin could be from this, or a fistula (Fig. 16-1).






        FIGURE 16-1 ▪ The ravages of perianal hidradenitis suppurativa in a patient with colonic Crohn disease.



      • Openings that track to the dentate line are anal fistulas. These should be adequately drained with either a vessel loop seton or a Penrose drain or both (Fig. 16-2).


      • Search the tracks for extensions, cavities, or sinuses, and make sure that everything is drained or unroofed.






        FIGURE 16-2 ▪ Draining anterior extensions of a perianal fistula using Penrose drains, while the primary track is drained by vessel loop setons.


    • If the symptoms and cellulitis do not settle down during the 24 hours after EUA, then another EUA is indicated.


    • If the sepsis still cannot be controlled by local means, then fecal diversion is indicated.


  • Is there perineal Crohn disease?



    • Perineal Crohn disease is an infiltration of the perineal tissue by Crohn disease. It is associated with a characteristic clinical appearance, and the majority of cases have perineal granulomas reported on biopsy.


    • Perineal Crohn disease is a contraindication to incisional surgery, as wounds don’t heal (Fig. 16-3A and B).


    • Perineal Crohn disease usually responds well to biologic treatment, and this can prepare the region for successful local repair.






FIGURE 16-3 ▪ A. An unhealed perianal wound in a patient with perineal Crohn disease. This wound had been present for over a year. Biopsy of the perineum revealed typical granulomas. B. Perineal Crohn disease: Unhealed wound from fistulotomy performed a year previously.


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Apr 13, 2020 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Crohn Anorectal Disease

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