Complicated Crohns; fistula, perianal disease and strictures

Question 1

How common are rectovaginal fistula
How do they present
how successful is treatment

Answer 1

10% female crohn’s patients with rectal/anal involvement
air/faeces in vagina, dyspareunia, perianal pain
unfortunately medical and surgical treatment is often unsuccessful and recurrence rates are high

Question 2

Are all fistula secondary to crohn’s disease

Answer 2

No, can be surgical related particularly if occurring in the early post operative setting more likely to be related to surgery

Question 3

What symptom may be caused by enteroenteric fistula

Answer 3

severe diarrhoea - by passed bowel

Question 4

which type of fistula is most likely to respond to medical therapy

Answer 4

perianal fistula

rectovaginal, enteroenteric and enterocutaneous are less likely to respond to medical therapy

Question 5

What are the weakness of TNF therapy in fistula management

Answer 5

1/3 pts primary non-responders
1/2 of responding patients lose response within 1-2 years
complete healing occurs in 30-50% - healing rates improved when TNF combined with seton placement or curettage of fistula track and also decrease recurrence rate

Question 6

what trough level should be targeted for healing fistula with inlix and ADA

Answer 6

> 10 for inflixi

>8-10 for ADA

Question 7

What stricture features are suitable for endoscopic dilatation

What % require redilatation and surgery

Answer 7

fibrotic
short <4cm
straight
anastomotic stricture vs de novo

at 2 years 70% re-dilation, 40% surgery