Fistulizing Crohns Disease
02.19.10
Fistulas are common in Crohns disease. A population-based study has shown a cumulative risk of 33% after 10 years and 50% after 20 years. Perianal fistulas were the most common (54%). Medical therapy is the main option for perianal fistula once abscesses, if present, have been drained, and should include antibiotics (both ciprofloxacin and metronidazole) and immunomodulators.
Infliximab should be reserved for refractory patients. Surgery is often necessary for internal fistulas. The appropriate treatment of patients with fistulas in the setting of Crohns disease requires a knowledge of the specific medical and surgical literature of fistulizing Crohn’s. The patient with symptomatic fistulizing Crohns disease may respond differently to specific medical therapy than a patient with symptomatic obstructing Crohns disease.
Certain medications that are useful for the treatment of patients with obstructive Crohns disease may not be helpful in the treatment of fistulas in patients with fistulizing Crohns disease (e.g., corticosteroids and mesalamine); in fact, some medications are believed to be detrimental (e.g., corticosteroids). Few studies have been performed to assess the efficacy of specific medications on fistulas directly.
To date, there has been only one published prospective randomized controlled trial that was designed to assess the efficacy and safety of a specific medication on fistulas in patients with Crohns disease; it showed clinical efficacy over placebo in a statistically significant manner. The judicious use of surgery remains an integral part of the management of certain presentations of fistulizing Crohns disease, and the appropriate integration of surgical and medical therapy is of paramount importance in the management of these patients.
This review provides an overview of pertinent medical and surgical literature as it pertains to management of patients with fistulizing Crohns disease. Remicade was also shown to be effective in reducing the number of open, draining fistulas, a painful complication of Crohns disease in which deep openings burrow from the bowel wall through the surface of the skin, causing drainage of mucous and/or fecal material. Remicade is the first product documented to reduce the number of open fistulas in a controlled clinical trial.
In a clinical study of 94 patients with fistulizing Crohns disease (42 patients had single fistula and 52 patients had multiple fistulas), 68 percent of those treated at the recommended dose of Remicade experienced closure of at least 50 percent of fistula(s) for four weeks or more compared with 26 percent of placebo-treated patients. More than one-half (55 percent) of patients with single or multiple fistula(s) treated with Remicade experienced a clinical effect demonstrated clinical response to treatment with Remicade developed an abscess in the area of the fistula between eight and 16 weeks after the last infusion.
“Remicade represents a significant advance in the treatment of Crohns disease,” said Stephen Hanauer, M.D., University of Chicago Medical Center, department of gastroenterology, and a principal investigator in the clinical trials. “These patients suffer terribly and we physicians now have an important option available to treat them.”