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Significant Medical and Surgical Morbidity in Perianal Crohn's Disease: Results from a Territory-Wide Study
Wing Yan Mak1, Oi Sze Mak2, Choon Kin Lee1,3
1Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Science, The Chinese University of Hong Kong, Hong Kong.
Insights
Perianal Crohn's disease (PCD) affects over 40% of patients at diagnosis, often presenting aggressively. Patients with PCD experience poor outcomes, including frequent antibiotic use and multiple surgeries.
Area of Science:
- Gastroenterology
- Inflammatory Bowel Disease Research
- Surgical Gastroenterology
Background:
- Perianal fistulas in Crohn's disease (CD) indicate a more aggressive disease course.
- The Hong Kong IBD Registry (HKIBDR) provides a platform for studying the epidemiology of perianal CD (PCD).
Purpose of the Study:
- To investigate the epidemiology and clinical outcomes of perianal Crohn's disease (PCD) in Hong Kong.
- To identify risk factors associated with the development of PCD.
- To analyze treatment patterns and long-term outcomes for patients with PCD.
Main Methods:
- Retrospective analysis of consecutive patients with PCD from the HKIBDR.
- Assessment of disease characteristics, treatments, and outcomes.
- Kaplan-Meier analysis to evaluate risks for medical and surgical therapies.
Main Results:
- 28.8% of 981 CD patients had perianal involvement, with 42.4% presenting initially with PCD.
- Common manifestations include perianal fistula (84.8%) and abscess (52.7%).
- Male sex, younger age at CD diagnosis, and penetrating phenotypes were linked to PCD development. High rates of antibiotic use (29.2%) and surgery (40.5%) were observed in fistulizing PCD. Cumulative surgery probability reached 77.7% by 96 months.
Conclusions:
- Perianal Crohn's disease is a significant complication, with over 40% of CD patients presenting with perianal manifestations.
- PCD is associated with poor outcomes, characterized by early onset, frequent antibiotic courses, and repeated surgical interventions.
- Long-term management of PCD requires careful consideration of medical and surgical treatment strategies.
Background:
The presence of perianal fistulas in Crohn's disease [CD] denotes increased disease aggressiveness. We studied the epidemiology and clinical outcomes of perianal CD [PCD] using the Hong Kong territory-wide IBD Registry [HKIBDR].
Methods:
Consecutive patients with PCD were identified from the HKIBDR, and disease characteristics, treatments, and outcomes were analysed. The risks for medical and surgical therapies were assessed using Kaplan-Meier analysis.
Results:
Among 981 patients with CD with 10530 patient-years of follow-up, 283 [28.8%] had perianal involvement, of which 120 [42.4%] were as first presentation. The mean age at diagnosis of PCD was 29.1 years, and 78.8% were male. The median follow-up duration was 106 months (interquartile range [IQR]: 65-161 months]. Perianal fistula [84.8%] and perianal abscess [52.7%] were the two commonest forms. Male, younger age at diagnosis of CD, and penetrating phenotypes were associated with development of PCD in multivariate analysis. Of 242 patients with fistulizing PCD, 70 [29.2%] required ≥5 courses of antibiotics, and 98 [40.5%] had ≥2 surgical procedures. Nine patients required defunctioning surgery and 4 required proctectomy. Eighty-four patients [34.7%] received biologics. Cumulative probabilities for use of biologics were 4.7%, 5.8%, and 8.6% at 12 months, 36 months, and 96 months, respectively, while the probabilities for surgery were 67.2%, 71.6%, and 77.7%, respectively. Five mortalities were recorded, including 2 cases of anal cancer, 2 CD-related complications, and one case of pneumonia.
Conclusion:
Over 40% of CD patients presented with perianal disease at diagnosis. Patients with PCD had poor outcome, with young age of onset, multiple antibiotic use, and repeated surgery.