Perianal Crohn's Disease

Perianal Crohn's disease usually is associated with involvement of another primary site of Crohn's disease. However, there is conflicting evidence on the relationship between proximal disease activity and perianal symptoms. Therefore, although it is reasonable to treat active proximal disease, symptomatic perianal disease may have to be treated on its own right. Hemorrhoids and anal fissures are best treated medically. Fistulae and abscesses are treated with control of sepsis and resolution of inflammation while preserving continence and quality of life. Abscesses require surgical drainage, which needs to be prolonged for healing to be complete. Fistulae may be treated with medications first, especially if the rectum is diseased. Refractory fistulae respond better to surgical treatment and sometimes require fecal diversion. The medical management of patients with perianal Crohn's disease consists of rectal mesalamine, systemic antibi-otics, immunosuppressive agents, and infliximab. The role of infliximab is evolving and it may reduce the need for surgical intervention in some cases. Perianal hygiene and skin protection help to reduce local discomfort.