As noted, an adequate history and physical examination is essential. If the patient has an abscess, it should be adequately drained before proceeding with medications. Not all patients require a colorectal surgeon, that is if the abscess has either drained spontaneously or been drained by incision. On the other hand, if there is persistent rectal pain and/or tenderness, or there are multiple draining sites, then a colorectal surgeon should be consulted to be certain that all pus has been adequately drained. In this situation, an EUA and/or MRI is indicated.
Although there have been multiple trials conducted throughout the world using sulfasalazine or mesalamine in the treatment of CD, there have never been any studies designed to study or reports indicating that these agents are efficacious in the treatment of perianal fistula (Present, 2003). In the vast majority of cases, mesalamine or sul-fasalazine will be maintained as part of the management of the active bowel disease, but again there is no reason to institute these agents if the major problem is perianal fistula.
In looking at the control trials using corticosteroids in the treatment of CD, neither the National Cooperative Crohn's Disease Study, nor the European Cooperative Crohn's Disease Study randomized patients for fistula, and there is, therefore, no data available for this subgroup of patients. In these two steroid placebo controlled trials the only deaths occurred in patients who were receiving steroids and who had internal fistula with the subsequent development of an abscess and overwhelming sepsis. Multiple controlled trials have been performed evaluating a newer steroid, budesonide, in the treatment of CD. Efficacy has been demonstrated. However, all patients with a fistula were excluded from these placebo controlled trials. There is, therefore, no control data suggesting that steroids should be instituted in patients who developed perianal complications and fistula. I have experienced multiple patients with longstanding disease going on to develop fistulas and abscesses for the first time after steroids are introduced. I have also seen a significant lack of healing when patients are taking steroids and attempts are made for closure with immunomodulatory agents (Present, 2002). It is my personal opinion that steroids are "con-traindicated" when trying to manage perianal fistulas, and if the bowel symptoms allow, I quickly withdraw them from the therapeutic regimen.
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