Perianal Crohn's disease--is it all bad news?

The outcome of treatment of perianal Crohn's disease was assessed in 127 patients.

A retrospective review of the case notes of 415 patients who were seen in the North East of Scotland between 1985 and 1989 was undertaken.

A total of 127 of 415 patients with Crohn's disease had perianal involvement. In 56 patients, perianal disease was the presenting complaint. Ninety-nine of the 127 patients had colonic involvement. Thirty-two were treated with metronidazole and 41 were treated with azathioprine, with at least temporary improvement in 91 and 68 percent, respectively. Seventy patients had treatment for fistula-in-ano, and in 50 percent of patients permanent healing was achieved. In general, treatment and outcome were largely related to the extent and severity of gut involvement. Proctectomy was performed in 32 patients (in 11 because of ongoing colonic disease). Only seven patients had proctectomy solely because of perianal disease. Proctectomy was necessary in 32 of 99 patients with colitis and perianal disease but in none of 28 patients without colonic involvement. Primary healing of the perineal wound was obtained in 17 patients, and only one patient has an unhealed perineal wound at the time of reporting.

Perianal Crohn's disease does not inevitably lead to panproctocolectomy. Cautious surgery for fistula when rectal inflammation is quiescent is worthwhile. Loss of bowel continuity is more likely when colitis coexists with perianal disease. Panproctocolectomy is often indicated because of the combination of colitis and perianal disease rather than for perianal disease alone.