Patients with Crohn's disease who develop symptomatic anorectal fistula pose a particular management challenge. When an initial medical-surgical approach does not achieve adequate fistula control, a defined next-line protocol guides the subsequent course of care.
Symptomatic anorectal fistula occurring in the setting of Crohn's disease. This population requires management that accounts for the underlying inflammatory bowel disease alongside the fistula itself.
The preceding treatment line combined biological (anti-TNF) therapy — including infliximab, adalimumab, or certolizumab — with a draining seton; patients not requiring drainage received antibiotic therapy with metronidazole and fluoroquinolones. Escalation to this protocol is indicated when that regimen fails to achieve a reduction of more than 50% in the number of draining fistulas by week 14.
This protocol involves definitive surgical intervention for the fistula tract — the specific procedure selected depends on individual patient anatomy and disease characteristics. Full procedural criteria and the clinical algorithm are available in the complete protocol.
DOI: 10.1097/DCR.0000000000002473
Anorectal fistula associated with Crohn's disease is typically managed with a combination of surgical and medical approaches.
Symptomatic, simple, low anal fistulas in carefully selected patients with Crohn's disease may be treated by lay-open fistulotomy.
Endorectal advancement flaps and the LIFT procedure may be used to treat fistula-in-ano associated with Crohn's disease.
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