Anorectal Crohn’s Disease
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Anorectal Crohn’s Disease
Anorectal Disease- A 24-year-old woman reports feculent vaginal discharge 8 months after spontaneous vaginal delivery complicated by a 4th-degree perineal laceration, which was previously repaired. Physical examination reveals a 3-mm rectovaginal fistula 2 cm proximal to the anal verge with significant thinning of the perineal body and a palpable sphincter defect anteriorly. Endoanal ultrasound confirms a 90° defect of the external sphincter at the anterior midline. The best next step in management is
- A 35-year-old woman presents to your office with recurrent perianal and inguinal pustular lesions and nodules with severe, extensive scarring and tunnel formation with ongoing drainage. The colonoscopy is normal, and she has no gastrointestinal symptoms. What is the best treatment to prevent recurrence?
- A 36-year-old patient was diagnosed with Crohn’s disease of the terminal ileum 4 years ago. She is currently in remission on infliximab; however, she is concerned about anal skin outgrowth that is frequently irritated. Physical examination reveals a 1.2-cm round anal skin tag that is soft, nontender with a smooth surface. Anoscopy shows normal appearing anorectal mucosa without evidence of perianal abscess or fistula. The most appropriate next step in management for this patient is
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- Anal Fissure and Anal Stenosis
Complex Anorectal Crohn's Disease
Benign Disease- A 45-year-old man presents to your office with complaints of bloating, constipation, and intermittent diarrhea over the last 3 months. He has a 20-year history of Crohn’s disease and is currently receiving biologic therapy. On physical examination, he is mildly distended, without peritonitis. Colonoscopy confirms a sigmoid stricture that cannot be traversed. The most appropriate treatment is:
- A 70-year-old man with history of perianal Crohn’s disease and 15-year history of an anal fistula presents to establish care. On examination, he has a right anterior anal fistula that appears chronic in nature. What is the best next step in management?
- A 35-year-old woman is taken to the operating room for a proctocolectomy with end ileostomy for Crohn’s disease–related colonic dysplasia. What is the most appropriate surgical management of the perineal dissection?
- A 50-year-old man with a history of ulcerative colitis presents for follow-up 6 months after emergent total abdominal colectomy with end ileostomy. He complains of pain and persistent drainage from the perianal area. Ileoscopy is normal. The pathology report from his surgical specimen demonstrates full-thickness inflammation and granulomas. What is the most appropriate next step?
- Benign Disease
- A 32-year-old female patient with Crohn’s disease presents with anal pain. She takes infliximab. On examination, there are large skin tags with an anal fistula draining pus and a 3 x 3 cm area of localized induration and fluctuance. The best next step in her management is
- A 19-year-old woman diagnosed with severe Crohn’s proctosigmoiditis 18 months ago suffers from debilitating perianal pain, swelling, discharge, and incontinence. She has undergone numerous anorectal operations including several incision and drainage procedures and seton placements for three separate fistulas, including one with a supralevator extension. She currently has three setons and a mushroom catheter in place with significant ulceration in the anal canal. In addition to prolonged courses of antibiotics, she had been on infliximab for 12 months prior to being on ustekinumab for the past 6 months without improvement. What is the best next course of action?
- A 55-year-old man presents with abdominal pain and rectal bleeding. He has a 20-year history of Crohn’s proctocolitis and has perianal disease. He was treated with infliximab for 5 years but developed anti–tumor necrosis factor (TNF) antibodies. He had an allergic reaction to adalimumab. He has been on usketinumab for the past year with minimal improvement. You drained two prior perirectal abscesses and placed setons in the past 2 years. He currently has minimal complaints from the indwelling setons. A recent colonoscopy confirmed the persistence of chronic active proctosigmoiditis without evidence of dysplasia on multiple biopsies. He reports signficant disruption of his life and work and "wants this disease controlled, even if it means an ostomy." On physical examination, the abdominal is soft and minimally tender. Anorectal examination shows a well-controlled transphincteric fistula with seton without evidence of sepsis. Which of the following surgical options is most appropriate for this patient?
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- A 34-year-old man has a constant, “dull ache” of the lower rectum accompanied by intermittent spontaneous rectal discharge. Imaging reveals a supralevator abscess with direct extension through the levators to the ischiorectal fossa. What is the next step in treatment?
- A 40-year-old woman with a history of Crohn's disease presents to your office with quiescent proctitis and a 4-mm rectovaginal fistula just above the anorectal ring. There is no appreciable sphincter defect. What is your best recommendation for repair?
- A 30-year-old man presents for evaluation of a nontender ulcer near the anus that has been present for the past few weeks. He has engaged in anal receptive intercourse recently with a new partner. On examination, a 1-cm slightly raised lesion with an erythematous center is noted near the anal canal. It is not tender to palpation. What is the appropriate treatment?
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