Summary

In the management of perianal CD, when a fistula develops appropriate diagnosis should be made by history, physical, colonoscopy, and small bowel series. If the fistula is simple, it should be drained and treated with antibiotics. If there is healing, it is my opinion that one or two antibiotics should be maintained for at least 6 to 12 months. I would use low doses of metronidazole 250 mg 3 times daily or ciprofloxacin 250 to 500 mg twice daily. If there is recurrence of the fistula and it drains freely, I would then add 6-MP/AZA to the regimen. If pain persists or the fistula occurs in a new site, I prefer to obtain an examination by a colorectal surgeon with an EUA. If the surgeon is not certain of the status, then an MRI should be added to the regimen. Setons should be placed to allow time for the 6-MP/AZA to promote healing. If the fistula heals with 6-MP/AZA, I would maintain this agent for 5 years or longer. If healing is not induced or maintained with 6-MP/AZA, a 3-course infusion of infliximab is indicated. I do not continue infliximab every 8 weeks, but rather maximize all therapy by giving adequate doses of antibiotics and 6-MP, then treat only after recurrence. It is my experience that not all patients will relapse and require infliximab every 8 weeks. If infliximab fails, a 7- to 10-day course of IV cyclosporin in a dose of 4 mg/kg is indicated.

Failure to respond to all of the above medical therapies would dictate proctectomy and a total colectomy if the CD is active in the remaining colon.

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