Ponad 7000 publikacji medycznych!
Statystyki za 2021 rok:
odsłony: 8 805 378
Artykuły w Czytelni Medycznej o SARS-CoV-2/Covid-19

Poniżej zamieściliśmy fragment artykułu. Informacja nt. dostępu do pełnej treści artykułu
© Borgis - Nowa Medycyna 2/2017, s. 86-97
*Małgorzata Kołodziejczak1, Iwona Sudoł-Szopińska1-3, Włodzimierz Zych1, 4
Current treatment options for Crohn’s fistula in ano – interdisciplinary problem
Współczesne leczenie przetok odbytu w chorobie Leśniowskiego-Crohna – problem interdyscyplinarny
1Warsaw Proctology Centre, Saint Elizabeth’s Hospital, Mokotów Medical Centre
Head of Centre: Associate Professor Małgorzata Kołodziejczak, PhD
2Department of Radiology, Eleonora Reicher National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw
Head of Department: Professor Iwona Sudoł-Szopińska, MD, PhD
3Department of Diagnostic Imaging, Second Faculty of Medicine, Medical University of Warsaw
Head of Department: Professor Wiesław Jakubowski, MD, PhD
4Polish Foundation of Gastroenterology, Warsaw
Head of Foundation: Bronisław Kotowski, MD
Streszczenie
Choroba Leśniowskiego-Crohna często, bo u 21-54% pacjentów, obejmuje dystalny odcinek przewodu pokarmowego. U prawie wszystkich chorych z zajęciem odbytnicy dochodzi do powstania przetoki odbytu. Objawy kliniczne przetoki są z reguły bardziej burzliwe niż przetoki o etiologii odkryptowej. Często jeszcze przed leczeniem operacyjnym występuje nietrzymanie stolca i gazów. Metodą z wyboru w diagnostyce przetok Leśniowskiego-Crohna jest rezonans magnetyczny, który ma przewagę nad endosonografią w obrazowaniu przetok wysokich, zwłaszcza ponadzwieraczowych oraz przetok rozgałęzionych i nawrotowych. Leczenie tych przetok ma charakter skojarzony i obejmuje farmakoterapię choroby podstawowej oraz leczenie chirurgiczne. W publikacji przedstawiono aktualne metody leczenia zachowawczego, wybrane rekomendacje European Crohn’s and Colitis Organisation (ECCO) 3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn’s Disease z 2016 roku dotyczące postępowania zachowawczego i zabiegowego w leczeniu przetok odbytu oraz rekomendacje Polskiego Klubu Koloproktologii w tym zakresie. Lektura tych dokumentów dowodzi, że sukces terapii wynika z interdyscyplinarnego podejścia (gastroenterolog, chirurg i radiolog) do pacjenta z przetoką Leśniowskiego-Crohna.
Summary
Crohn’s disease frequently (in 21-54% of cases) involves the distal segment of the gastrointestinal tract. An anal fistula develops in nearly all patients with involved rectum. Its clinical signs tend to be more dramatic than those of fistulae with the cryptoglandular aetiology. Stool and gas incontinence is often seen before surgery. Magnetic resonance imaging is the method of choice in the diagnosis of fistulae associated with Crohn’s disease. This modality is superior to endosonography since it is able to visualise high fistulae, particularly supra-sphincteric, branching and recurrent. Their treatment is combined and encompasses pharmacotherapy for the underlying disease and surgery. This paper presents current methods of conservative treatment, selected recommendations of the European Crohn’s and Colitis Organisation (ECCO) 3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn’s Disease from 2016 on conservative and surgical treatment of anal fistulae as well as recommendations of the Polish Coloproctology Club. These documents demonstrate that the success of therapy results from the interdisciplinary approach (gastroenterologist, surgeon and radiologist) to a patient with Crohn’s disease.



Introduction
Crohn’s disease frequently (in 21-54% of cases) involves the distal segment of the gastrointestinal tract. Nearly all patients develop an anal fistula, often a complex one, i.e. with branching and communication with the neighbouring organs (e.g. rectovaginal, rectovesical fistulae). Inflammatory lesions in this location also include non-healing fissures, inflammatory infiltrations and abscesses; patients often develop anorectal stenosis and anodermal flap hypertrophy.
In nearly half of the cases Crohn’s disease is present exclusively in the anorectal area. The presence of inflammatory lesions in the rectum is considered to be a negative prognostic factor for the course of the disease (1). In addition, a relationship between the serological and genetic type of a Crohn’s disease patient and the presence of inflammatory lesions in the rectum has been proven (2).
Population studies have demonstrated that the prevalence of fistulae increases with the duration of the disease and that fistulae are found in 21 to 23% of patients, including approximately 12% in the first year of the disease to 15% after five years, 21% after ten years, to as many as 26% of individuals after twenty years of the disease. There also exists a relationship between the occurrence of a fistula and the location of the underlying disease (3). In the case of inflammatory lesions that involve the ileum 12% of patients develop an anorectal fistula; with ileocaecal involvement 15% of patients develop an anal fistula; if the colon is involved, but the rectum is unaffected, approximately 41% of patients develop a fistula, whereas if the rectum is involved as well, a fistula occurs in 92% of patients. Perianal lesions may either precede clinically overt Crohn’s disease or be the first symptom of the disease, or co-occur with the intestinal manifestation (3).
Clinical presentation
The clinical symptoms of anal fistula associated with Crohn’s disease are usually more dramatic than those of cryptoglandular fistula. The characteristic symptoms of Crohn’s disease include pain around the anus resulting from partial stenosis of fistula canals and pus retention. Patients report leaking pus from the anus or from fistulae, oedema of the surrounding tissues, recurrent inflammation of the anus or abscesses. In the absence of appropriate surgical drainage septic complications may occur. Stool and gas incontinence is often seen already before surgery. It is caused by inflammatory lesions of the rectum and damage to sensory receptors of the transition zone responsible for the differentiation of rectal contents and by diarrhoeal stools and unproductive straining typical for the disease. In a large number of cases fistulae associated with Crohn’s disease are complex: high, branching (including horseshoe fistulae), often with concomitant abscesses or pus spillages in the ischiorectal and pelvic rectal fossae. They may form numerous internal outlets (multiple fistulae) or have numerous external openings (fig. 1-3).
Fig. 1. High branching fistula with multiple external outlets
Fig. 2. Branching fistula with a drain
Fig. 3. Seton drainage of a branching fistula – postoperative image
For endoscopically and histopathologically confirmed Crohn’s disease the diagnosis of a fistula is usually not difficult. However, for a person who reports to a physician with an anal fistula for the first time, the following should be taken into account in differential diagnosis (4):
– branching cryptoglandular fistulae,
– perineal apocrine glands inflammation,
– fistula in patients with compromised immunity (e.g. associated with HIV infection),
– complicated pilonidal cyst,
– furunculosis.
Aetiology and pathogenesis
The aetiology of anal fistulae associated with Crohn’s disease has not been fully discovered. According to one theory they develop as a result of penetration of abscesses from the side of the rectum or anal canal. It has not been fully confirmed if in every case of abscess the original aetiological factor is anal crypt infection. The current discussions focus on intestinal barrier damage and the role of genetic factors, changed intestinal microbiota and the activity of the immune system of the intestine. The development of inflammation in the rectal wall results from excessive activation of the immune system with leukocyte migration, uninhibited by feedback. Fistulae develop following epithelial damage associated with inflammation whose repair is compromised as a result of inhibited migration of fibroblasts to the lamina propria at the site of the damage (5). The function of the fibroblasts is taken over by the intestinal epithelium which transforms into myofibroblasts as a result of epithelial-mesenchymal transition mediated by cytokines: TGF-beta, TNF-alpha and IL-13, and other mediators. The intestinal epithelium cells lining the fistula canal also acquire the features of mesenchymal cells (6, 7). Another proposed mechanism of fistula formation is remodelling of the extracellular matrix, which is indicated by the increased expression of MMP-3 and MMP-9 metalloproteinases observed within the perimeter of the fistula canal (7). Bacterial infection may play a role, similarly to cryptoglandular fistulae. A link between NOD2 gene polymorphism and the risk of fistula formation has also been demonstrated (8).
Classification of fistulae associated with Crohn’s disease
Crohn’s anal fistulae, as do cryptoglandular fistulae, are included in the classic Parks’ classification, which divides fistulae into 4 types depending on the anatomical route of the fistula canal in relation to the external anal sphincter muscle (9). However, considering the specific nature of the disease, the American Gastroenterological Association has developed a separate classification of Crohn’s fistulae (10). It distinguishes between simple and complex fistulae. Simple fistulae include the ones which run below the dentate line, i.e. low intersphincteric and low transsphincteric fistulae with a single internal opening, without abscesses. All the remaining fistulae – complex fistulae are the ones which run above the dentate line, i.e. high intersphincteric, high transsphincteric, suprasphincteric and extrasphincteric fistulae, with multiple external openings, with possible concomitant abscesses or rectal stenosis and fistulae which communicate with the neighbouring organs (e.g. vagina, urinary bladder). The above classification does not account for the number of internal openings, although one may presume that all fistulae with more than one internal opening should be treated as multiple and complex.
Diagnostic investigation
Classically, the diagnostic investigation consists of history taking, physical examination, including primarily rectal examination, and additional examinations, such as endoscopy (to evaluate the extent and intensity of inflammatory lesions) and imaging (to determine the route of the fistula).
An element of diagnostic investigation which is often essential for the right diagnosis is examination under anaesthesia (EUA), which should be conducted in an operating room. This allows for performing drainage of the fistula canal if necessary and thus for limiting inflammation and preventing abscesses.
Diagnostic imaging
The basic imaging examination for the diagnosis of anal fistulae is transrectal ultrasound (endosonography). It is highly effective for the pre- and postoperative diagnosis of the majority of anal fistulae, especially simple and primary (non-recurrent) as well as low fistulae. Endosonography visualises anal sphincters very well (11-16). The disadvantage of this method is limited imaging field and insufficient differentiation between tissues, especially between a recurrent fistula and a scar.

Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
  • Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
  • Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
  • Aby kupić kod proszę skorzystać z jednej z poniższych opcji.

Opcja #1

24

Wybieram
  • dostęp do tego artykułu
  • dostęp na 7 dni

uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony

Opcja #2

59

Wybieram
  • dostęp do tego i pozostałych ponad 7000 artykułów
  • dostęp na 30 dni
  • najpopularniejsza opcja

Opcja #3

119

Wybieram
  • dostęp do tego i pozostałych ponad 7000 artykułów
  • dostęp na 90 dni
  • oszczędzasz 28 zł
Piśmiennictwo
1. Aguilera-Castro L, Ferre-Aracil C, Garcia-Garcia-de-Paredes A et al.: Management of complex perianal Crohn’s disease. Ann Gastroenterol 2017; 30(1): 33-44.
2. Kaur M, Panikkath D, Yan X et al.: Perianal Crohn’s Disease is Associated with Distal Colonic Disease, Stricturing Disease Behavior, IBD-Associated Serologies and Genetic Variation in the JAK-STAT Pathway. Inflamm Bowel Dis 2016; 22(4): 862-869.
3. Schwartz DA, Loftus EV Jr, Tremaine WJ et al.: The natural history of fistulizing Crohn‘s disease in Olmsted County, Minnesota. Gastroenterology 2002; 122(4): 875-880.
4. Kołodziejczak M: Rozpoznawanie i leczenie przetok w chorobie Leśniowskiego-Crohna. [W:] Kołodziejczak M, Sudoł-Szopińska I (red.): Diagnostyka i leczenie ropni i przetok odbytu. Wydawnictwo Borgis, Warszawa 2008: 207-215.
5. Dignass AU: Mechanisms and modulation of intestinal epithelial repair. Inflamm Bowel Dis 2001; 7: 68-77.
6. Frei SM, Hemsley C, Pesch T et al.: The role for dickkopf-homolog-1 in the pathogenesis of Crohn’s disease-associated fistulae. PLoS One 2013; 8: e78882.
7. Scharl M, Rogler G: Pathophysiology of fistula formation in Crohn’s disease. World J Gastrointest Pathophysiol 2014; 5: 205-212.
8. Radlmayr M, Török HP, Martin K, Folwaczny C: The c-insertion mutation of the NOD2 gene is associated with fistulizing and fibrostenotic phenotypes in Crohn’s disease. Gastroenterology 2002; 122: 2091-2092.
9. Parks AG, Gordon PH, Hardcastle JD: A classification of fistula in ano. Br J Surg 1976; 63: 1-12.
10. Sandborn WJ, Fazio VW, Feagan BG, Hanauer SB: AGA technical review on perianal Crohn’s disease. Gastroenterology 2003; 125: 1508-1530.
11. Burdan F, Sudoł-Szopińska I, Starosławska E et al.: Magnetic resonance imaging and endorectal ultrasound for diagnosis of rectal lesions. Eur J Med Res 2015; 20(1): 4.
12. Kołodziejczak M, Santoro GA, Obcowska A et al.: Three-dimensional endoanal ultrasound is accurate and reproducible in determining type and height of anal fistulae. Eur J Med Res 2015; 20: 4.
13. Criad JM, Salto LG, Rivas PF et al.: MR Imaging Evaluation of Perianal Fistulas: Spectrum of Imaging Features. Radio Graphics 2012; 32:175-194.
14. van Outryve M, Pelckmans P, Fierens H et al.: Transrectal ultrasonographic examination of the anal sphincter. Acta Gastroenterol Belg 1994; 57(1): 26-27.
15. Manes G, Maconi G, Saibeni S: New horizons in the imaging of perianal Crohn’s disease: transperineal ultrasonography. Expert Rev Gastroenterol Hepatol 2017; 28: 1-8.
16. van Outryve MJ, Pelckmans PA, Michielsen PP, van Maercke YM: Value of transrectal ultrasonography in Crohn’s disease. Gastroenterology 1991; 101(5): 1171-1177.
17. Beckingham IJ, Spencer JA, Ward J et al.: Prospective evaluation of dynamic contrast enhanced magnetic resonance imaging in the evaluation of fistula in ano. Br J Surg 1996; 83(10): 1396-1398.
18. Buchanan G, Halligan S, Williams A et al.: Effect of MRI on clinical outcome of recurrent fistula-in-ano. Lancet 2002; 360(9346): 1661-1662.
19. Alabiso ME, Iasiello F, Gianluca Pellino G et al.: 3D-EAUS and MRI in the Activity of Anal Fistulas in Crohn’s Disease. Gastroenterology Res Pract 2016; 2016: ID 1895694.
20. Bernstein LH, Frank MS, Brandt LJ, Boley SJ: Healing of perineal Crohn’s disease with metronidazole. Gastroenterology 1980; 79(2): 357-365.
21. Brandt LJ, Bernstein LH, Boley SJ, Frank MS: Metronidazole therapy for perineal Crohn’s disease: a follow-up study. Gastroenterology 1982; 83(2): 383-387.
22. Thia KT, Mahadevan U, Feagan BG et al.: Ciprofloxacin or metronidazole for the treatment of perianal fistulas in patients with Crohn’s disease: a randomized, double-blind, placebo-controlled pilot study. Inflamm Bowel Dis 2009; 15(1): 17-24.
23. Khan KJ, Ullman TA, Ford AC et al.: Antibiotic therapy in inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterology 2011; 106(4): 661-673.
24. Pearson DC, May GR, Fick GH, Sutherland LR: Azathioprine and 6-mercaptopurine in Crohn disease. A meta-analysis. Ann Intern Med 1995; 123(2): 132-142.
25. Korelitz BI, Adler DJ, Mendelsohn RA, Sacknoff AL: Long-term experience with 6-mercaptopurine in the treatment of Crohn’s disease. Am J Gastroenterology 1993; 88(8): 1198-1205.
26. Present DH, Rutgeerts P, Targan S et al.: Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 1999; 340(18): 1398-1405.
27. Sands BE, Anderson FH, Bernstein CN et al.: Infliximab maintenance therapy for fistulizing Crohn’s disease. N Engl J Med 2004; 350: 876-885.
28. Lichtenstein GR, Yan S, Bala M et al.: Infliximab maintenance treatment reduces hospitalizations, surgeries, and procedures in fistulizing Crohn‘s disease. Gastroenterology 2005; 128(4): 862-869.
29. Ricart E, Panaccione R, Loftus EV et al.: Infliximab for Crohn’s disease in clinical practice at the Mayo Clinic: the first 100 patients. Am J Gastroenterology 2001; 96(3): 722-729.
30. Farrell RJ, Shah SA, Lodhavia PJ et al.: Clinical experience with infliximab therapy in 100 patients with Crohn’s disease. Am J Gastroenterology 2000; 95(12): 3490-3497.
31. Bouguen G, Siproudhis L, Gizard E et al.: Long-term outcome of perianal fistulizing Crohn’s disease treated with infliximab. Clin Gastroenterol Hepatol 2013; 11: 975-981.
32. Hanauer SB, Sandborn WJ, Rutgeerts P et al.: Human anti-tumor necrosis factor monoclonal antibody (adalimumab) in Crohn‘s disease: the CLASSIC-I trial. Gastroenterology 2006; 130(2): 323-333.
33. Sandborn WJ, Rutgeerts P, Enns R et al.: Adalimumab induction therapy for Crohn disease previously treated with infliximab: a randomized trial. Ann Intern Med 2007; 146(12): 829-838.
34. Lichtiger S, Binion DG, Wolf DC et al.: The CHOICE trial: adalimumab demonstrates safety, fistula healing, improved quality of life and increased work productivity in patients with Crohn‘s disease who failed prior infliximab therapy. Aliment Pharmacol Therapeutics 2010; 32(10): 1228-1239.
35. Sandborn WJ, Feagan BG, Stoinov S et al.: Certolizumab pegol for the treatment of Crohn’s disease. N Engl J Med 2007; 357(3): 228-238.
36. West RL, van der Woude CJ, Hansen BE et al.: Clinical and endosonographic effect of ciprofloxacin on the treatment of perianal fistulae in Crohn’s disease with infliximab: a double-blind placebo-controlled study. Aliment Pharmacol Therapeutics 2004; 20(11-12): 1329-1336.
37. Dewint P, Hansen BE, Verhey E et al.: Adalimumab combined with ciprofloxacin is superior to adalimumab monotherapy in perianal fistula closure in Crohn’s disease: a randomised, double-blind, placebo controlled trial (ADAFI). Gut 2014; 63(2): 292-299.
38. Egan LJ, Sandborn WJ, Tremaine WJ: Clinical outcome following treatment of refractory inflammatory and fistulizing Crohn’s disease with intravenous cyclosporine. Am J Gastroenterology 1998; 93(3): 442-448.
39. Sandborn WJ, Present DH, Isaacs KL et al.: Tacrolimus for the treatment of fistulas in patients with Crohn‘s disease: a randomized, placebo-controlled trial. Gastroenterology 2003; 125(2): 380-388.
40. Sandborn WJ, Fazio VW, Feagan BG et al.: AGA technical review on perianal Crohn’s disease. Gastroenterology 2003; 125(5): 1508-1530.
41. de la Portilla F, Alba F, Garcia-Olmo D et al.: Expanded allogeneic adipose-derived stem cells (eASCs) for the treatment of complex perianal fistula in Crohn’s disease: results from a multicenter phase I/IIa clinical trial. Int J Colorectal Dis 2013; 28(3): 313-323.
42. Ciccocioppo R, Bernardo ME, Sgarella A et al.: Autologous bone marrow-derived mesenchymal stromal cells in the treatment of fistulising Crohn’s disease. Gut 2011; 60(6): 788-798.
43. Marzo M, Felice C, Pugliese D et al.: Management of perianal fistulas in Crohn’s disease: An up-to-date review. World J Gastroenterol 2015; 21(5): 1394-1403.
44. Haennig A, Staumont G, Lepage B et al.: The results of seton drainage combined with anti-TNFα therapy for anal fistula in Crohn’s disease. Colorectal Dis 2015; 17(4): 311-319.
45. Soltani A, Kaiser AM: Endorectal advancement flap for cryptoglandular or Crohn’s fistula-in-ano. Dis Colon Rectum 2010; 53: 486-495.
46. Gingold DS, Murrell ZA, Fleshner PR: A prospective evaluation of the ligation of the intersphincteric tract procedure for complex anal fistula in patients with Crohn’s disease. Ann Surg 2014; 260: 1057-1061.
47. Gionchett P 3rd, Dignass A, Danese S et al.: European Evidence-based Consensus on the Diagnosis and Management of Crohn’s Disease 2016. Part 2: Surgical Management and Special Situations. J Crohns Colitis 2017; 11(2): 135-149.
otrzymano: 2017-04-13
zaakceptowano do druku: 2017-05-04

Adres do korespondencji:
*Małgorzata Kołodziejczak
Warszawski Ośrodek Proktologii Szpital św. Elżbiety – Mokotowskie Centrum Medyczne
ul. Goszczyńskiego 1, 02-615 Warszawa
tel. +48 (22) 542-08-16
drkolodziejczak@o2.pl

Nowa Medycyna 2/2017
Strona internetowa czasopisma Nowa Medycyna