A0410 - Biologic Therapies for Isolated Recurrent, Persistent Complex Perianal Fistulas Without Luminal Crohn's Disease

Sunday, October 23, 2022

5:00 PM – 7:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

Hannah W. Fiske, MD

Brown University/Rhode Island Hospital
Providence, RI

Hannah W. Fiske, MD¹, Chung Sang Tse, MD², Sean Fine, MD, MS³
¹Brown University/Rhode Island Hospital, Providence, RI; ²UC San Diego, La Jolla, CA; ³Brown University, Providence, RI

Introduction: Isolated complex perianal fistulas are abnormal connections between the epithelial surfaces of the anal canal and the perianal skin, meeting criteria for complex perianal fistula but without evidence of inflammatory bowel disease (IBD). While over half of patients with Crohn’s disease (CD) have perianal fistulas, isolated perianal CD is rare. Here we discuss five cases of patients presenting with isolated recurrent complex perianal fistula, and we describe their diagnostic evaluation, attempted therapies, and outcomes.

Case Description/Methods: Five adults (3 women, 2 men; mean age 38 years old) with no prior GI symptoms/diseases initially presented with perianal pain (3/5), perirectal mass (2/5), diarrhea (1/5), and abdominal pain (1/5) (Table 1). All patents underwent exam under anesthesia (EUA) with incision and drainage (I&D) of perirectal abscesses, and setons were placed in perianal/rectal fistulas in 4/5 cases. Each patient had colonoscopy without evidence of inflammation on endoscopy or histology. Radiographic imaging (MRIs, MREs, and CT) revealed fistulas and abscesses but no evidence of luminal inflammation. All patients were treated with antibiotics and 4/5 received biologic therapy (Adalimumab, Infliximab, or Ustekinumab). Despite surgical and medical management, complex perianal fistulas were persistent in all patients at follow-up after an average of 45 months.

Discussion: For patients who develop recurrent complex fistulas, a presumptive diagnosis of CD is often made. However, patients who present with complex perianal fistulas in the absence of the luminal inflammation characteristically found in CD are said to have isolated perianal disease (IPD). It is unclear whether IPD represents truly isolated severe cryptoglandular fistulas or early presentation of undiagnosed CD, which renders the best treatment approach a clinical dilemma. IPD is classically treated with antibiotics and local surgical intervention, whereas perianal CD treatment is more complex, incorporating the use of immunosuppressive therapy. The cases described in our cohort reveal the importance of a multimodal approach when treating IPD in the absence of luminal findings of CD. While classic medications for CD are unlikely to succeed when used alone for IPD, their incorporation into the treatment regimen may be critical in achieving eventual resolution of perianal disease. Given the similarity in management, it is important to consider CD in the differential for IPD patients even in the absence of luminal findings.

PT #	Initial Presentation	Diagnostic Evaluations	Subsequent Diagnosis	Medical Therapies Attempted	Surgical Procedures	Ultimate Diagnosis and Plan
(1) 39F	Painful perianal mass, presumed to be an abscess or hemorrhoids	Flexible sigmoidoscopy Colonoscopy with bx MRI EUA	Refractory perirectal and rectovaginal fistula with abscess	IBD medications: Adalimumab Methotrexate Non-IBD medical therapies: Ciprofloxacin Metronidazole Amoxicillin-Clavulanic acid Prednisone	I&D Seton placement Fistulectomy with sphincterotomy Diverting sigmoid colostomy Fistulotomy	Non-healing cryptoglandular anal fistula complicated by surgery Discontinue IBD therapy Surgical f/u with consideration for clinical trial of stem cell injection or transperitoneal repair
(2) 34M	Abdominal pain, diagnosed with sigmoid diverticulitis	Colonoscopy with bx MRI MRE CT scan EUA	Refractory perianal fistula with abscess	IBD medications: Infliximab Ustekinumab Tacrolimus Azathioprine Non-IBD medical therapies: Metronidazole Ciprofloxacin	I&D Seton placement	Isolated perianal disease in the setting of presumed CD Chronic treatment with chronic, cyclical abx (Ciprofloxacin or Amoxicillin-Clavulanic acid IBD-directed therapy (Azathioprine + Infliximab; will consider Upadacitinib once approved by the FDA) Planning for surgical f/u
(3) 43M	Painful perianal mass, presumed to be a rectal abscess	Colonoscopy with bx MRI EUA	Refractory perianal abscess	Non-IBD medical therapies: Amoxicillin-Clavulanic acid	I&D	Isolated cryptoglandular abscess with potential hemorrhoids No need for chronic antibiotics Sitz baths and PrepH as needed If symptoms worsen will plan for EUA and surgical f/u
(4) 24F	Perianal pain, diagnosed as perianal abscess with fistula	Colonoscopy with bx MRI EUA	Refractory perianal abscess, inflammatory arthropathy	IBD medications: Adalimumab Infliximab Azathioprine Non-IBD medical therapies: Ciprofloxacin Metronidazole	I&D Seton placement	Presumed CD with perianal disease and inflammatory arthropathy IBD-directed therapy (Azathioprine + Infliximab) Planning for surgical f/u
(5) 50F	Diarrhea and rectal ulcers, presumed to have CD	Colonoscopy with bx MRI CT EUA	Refractory perianal fistula with abscess	IBD medications: Infliximab Non-IBD medical therapies: Colchicine Prednisone	I&D Seton placement Perineal debridement Lay open fistulotomy	Presumed CD with perianal disease IBD-directed therapy (Infliximab)

Table: Table 1.
Abbreviations:
Bx = biopsies. CD = Crohn’s disease. EUA = exam under anesthesia. F = female. F/U = follow up. I&D = incision and drainage. IBD = inflammatory bowel disease. M = male. MRE = magnetic resonance elastography. MRI = magnetic resonance imaging.

Disclosures:

Hannah Fiske indicated no relevant financial relationships.

Chung Sang Tse indicated no relevant financial relationships.

Sean Fine: Bristol Meyers Squibb – Consultant.

Hannah W. Fiske, MD¹, Chung Sang Tse, MD², Sean Fine, MD, MS³. A0410 - Biologic Therapies for Isolated Recurrent, Persistent Complex Perianal Fistulas Without Luminal Crohn's Disease, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.