Perianal disease

Patients with moderate to severe active CD may be treated with oral corticosteroids, such as prednisone 40 to 60 mg daily.2 Budesonide 9 mg orally once daily may be used for moderate active CD involving the terminal ileum or ascending colon. Infliximab is an effective alternative to corticosteroid therapy for patients with moderate to severe CD, including patients with fistulizing or perianal disease.15,37-39 The recommended regimen for induction of remission is infliximab 5 mg/kg at weeks 0, 2, and 6 it is effective in inducing remission in... 

An increasing number of both clinical and laboratory-derived observations support the importance of luminal components in driving the inflammatory response in ulcerative colitis and Crohn s disease. Although its role is unclear, antibiotic therapy is commonly used in clinical practice for the treatment of moderately to severely active ulcerative colitis. Metronidazole and/or ciprofloxacin are currently employed in active Crohn s disease, particularly in patients with colonic involvement and with perianal disease. Rifaximin, a rifamycin-derived antibiotic, is characterized by a wide range of antibacterial activity and a very low systemic absorption. Some preliminary data show its efficacy in severe active ulcerative colitis, pouchitis and prevention of postoperative recurrence in Crohn s disease. 

Emollient laxatives are not effective in treating constipation but are used mainly to prevent constipation. They may be helpful in situations where straining at stool should be avoided, such as after recovery from myocardial infarction, with acute perianal disease, or after rectal surgery. 

Therapeutic pyramid approach to inflammatory bowel diseases. Treatment choice is predicated on both the severity of the illness and the responsiveness to therapy. Agents at the bottom of the pyramid are less efficacious but carry a lower risk of serious adverse effects. Drugs may be used alone or in various combinations. Patients with mild disease may be treated with 5-aminosalicylates (with ulcerative colitis or Crohn s colitis), topical corticosteroids (ulcerative colitis), antibiotics (Crohn s colitis or Crohn s perianal disease), or budesonide (Crohn s ileitis). Patients with moderate disease or patients who fail initial therapy for mild disease may be treated with oral corticosteroids to promote disease remission immunomodulators (azathioprine, mercaptopurine, methotrexate) to promote or maintain disease remission or anti-TNF antibodies. Patients with moderate disease who fail other therapies or patients with severe disease may require intravenous corticosteroids, anti-TNF antibodies, or surgery. Natalizumab is reserved for patients with severe Crohn s disease who have failed immunomodulators and TNF antagonists. Cyclosporine is used primarily for patients with severe ulcerative colitis who have failed a course of intravenous corticosteroids. TNF, tumor necrosis factor. 

The EM forms of Paget disease occur predominantly in females as vulvar or perianal disease but may also occur in males and at other sites. 

Antibiotics can be used as either (1) adjunctive treatment along with other medications for active IBD (2) treatment for a specific complication of Crohn s disease or (3) prophylaxis for recurrence in postoperative Crohn s disease. Metronidazole, ciprofloxacin, and clarithromycin are the antibiotics used most frequently. They are more beneficial in Crohn s disease involving the colon than in disease restricted to the Ueum. Specific Crohn s disease-related complications that may benefit from antibiotic therapy include intra-abdominal abscess and inflammatory masses, perianal disease (including fistulas and perirectal abscesses), small bowel bacterial overgrowth secondary to partial small bowel obstruction, secondary infections with organisms such as Clostridium difficile, and postoperative complications. Metronidazole may be particularly effective for the treatment of perianal disease. Postoperatively, a 3-month course of metronidazole (20 mg/kg/day) can prolong the time to both endoscopic and clinical recurrence. 

Of special interest in this group of youngsters has been the response of severe rectal and perianal disease to total parenteral nutrition. In one boy (R.G.) who failed to respond to several operations, his upper intestinal tract remission has been accompanied by complete healing of multiple perianal fistulae. In the girl (M.P.) who had an ileocolectomy and post operative parenteral nutrition, multiple perianal fistulae have healed. In this patient the effect of resection of intra-abdominal disease must be considered, but the rapidity of the perineal improvement was similar to that noted for R.G. Lastly, I.W. with severe anal granulomata and ulcers sustained marked improvement of the anal involvement after a brief course of parenteral alimentation. 

Crohn s disease Fever, tachycardia (with severe disease), dehydration, arthritis, abdominal mass and tenderness, perianal fissure or fistula... 

American Gastroenterological Association technical review on perianal Crohn s Disease. Gastroenterology 2003 125 1508-1530. 

As with ulcerative colitis, the presentation of Crohn s disease is highly variable (Table 26-4). A single episode may not be followed by further episodes, or the patient may experience continuous, unremitting disease. A patient may present with diarrhea and abdominal pain or a perirectal or perianal lesion. 

Cyclosporine is not recommended for Crohn s disease except for patients with symptomatic and severe perianal or cutaneous fistulas. The dose of cyclosporine is important in determining efficacy. An oral dose of 5 mg/kg/ day was not effective, whereas 7.9 mg/kg/day was effective. However, toxic effects limit application of the higher dosage. Dosage should be guided by cyclosporine whole-blood concentrations. 

Scrotal and Perianal Candidiasis. These manifestations usually accompany genital disease, but may also develop independently. On the scrotum candidiasis often presents as erythema. 

In contrast to ulcerative colitis, about 50% of patients with Crohn s colitis will respond to metronidazole given for up to 3 months, although adverse effects including alcohol intolerance, and peripheral neuropathy from such prolonged therapy often limit its use. The drug is also helpful in controlling perianal and small bowel disease and it decreases the incidence of anastamotic recurrence after surgery. Other antimicrobials, particularly ciprofloxacin may also be effective. 

A 35-year-old woman with ileal and perianal Crohn s disease took four doses of celecoxib for an orthopedic injury, and had rectal bleeding, severe abdominal pain, and worse diarrhea. Celecoxib was withdrawn and her symptoms returned to baseline within 5 days. 

Contact allergy should always be suspected in patients with anogenital dermatitis, especially if the perianal area is involved. In patients with other chronic inflammatory diseases of the anogenital region, for example lichen sclerosus, contact allergy should also be excluded, since long-term use of topical medicaments on compromised skin carries an increased risk of sensitization. 

The extravulvar form of the disease presents in the perianal areas as metastatic disease from sites that may... 

Metastatic colorectal carcinoma presenting as perianal-vulvar Paget disease CK7 (negative), CK20+, CDX2+, CEA+, CCDFP-15 (negative)... 

Nowak MA, Guerriere-Kovach P, Pathan A, et al. Perianal Paget s disease distinguishing primary and secondary lesions using immunohistochemical smdies including gross cystic disease fluid protein-15 and cytokeratin 20 expression. Arch Pathol Lab Med. 1998 122 1077-1081. 

Lowry, P. W., Weaver, A. L., Tremaine, W. J., and Sandbom, W. J. (1999). Combination therapy with oral tacrolimus (FK506) and azathioprine or 6-mercaptopurine for treatment-refractory Crohn s disease perianal fistulae. Inflam. Bowel Dis. 5, 239-245. 

Metronidazole is used increasingly as primary therapy for pseudomembranous colitis due to Clostridium difficile infection. At doses of250-500 mg orally three times daily for 7-14 days, metronidazole is effective and less expensive than oral vancomycin. Metronidazole also is used in patients with Crohn s disease who have perianal fistulas or significant colonic disease fsee Chapter 38). 

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