Krisztina B Gecse1, Willem Bemelman2, Michael A Kamm3, Jaap Stoker4, Reena Khanna5, Siew C Ng6, Julián Panés7, Gert van Assche8, Zhanju Liu9, Ailsa Hart10, Barrett G Levesque11, Geert D'Haens1. 1. Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands Robarts Research Institute, Amsterdam, The Netherlands. 2. Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. 3. St. Vincent's Hospital and University of Melbourne, Melbourne, Australia. 4. Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. 5. Robarts Research Institute, London, Ontario, Canada University of Western Ontario, London, Ontario, Canada. 6. Department of Medicine and Therapeutics, Institute of Digestive Disease, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, Hong Kong. 7. Department of Gastroenterology, Hospital Clinic Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain. 8. Department of Gastroenterology, University of Leuven, Leuven, Belgium. 9. Department of Gastroenterology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China. 10. APRG, Imperial College, London, UK IBD Unit, St. Mark's Hospital, London, UK. 11. Robarts Research Institute, San Diego, CA, USA Division of Gastroenterology, University of California San Diego, La Jolla, California, USA.
Abstract
OBJECTIVE: To develop a consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease (pCD), based on best available evidence. METHODS: Based on a systematic literature review, statements were formed, discussed and approved in multiple rounds by the 20 working group participants. Consensus was defined as at least 80% agreement among voters. Evidence was assessed using the modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. RESULTS: Highest diagnostic accuracy can only be established if a combination of modalities is used. Drainage of sepsis is always first line therapy before initiating immunosuppressive treatment. Mucosal healing is the goal in the presence of proctitis. Whereas antibiotics and thiopurines have a role as adjunctive treatments in pCD, anti-tumour necrosis factor (anti-TNF) is the current gold standard. The efficacy of infliximab is best documented although adalimumab and certolizumab pegol are moderately effective. Oral tacrolimus could be used in patients failing anti-TNF therapy. Definite surgical repair is only of consideration in the absence of luminal inflammation. CONCLUSIONS: Based on a multidisciplinary approach, items relevant for fistula management were identified and algorithms on diagnosis and treatment of pCD were developed. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
OBJECTIVE: To develop a consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease (pCD), based on best available evidence. METHODS: Based on a systematic literature review, statements were formed, discussed and approved in multiple rounds by the 20 working group participants. Consensus was defined as at least 80% agreement among voters. Evidence was assessed using the modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. RESULTS: Highest diagnostic accuracy can only be established if a combination of modalities is used. Drainage of sepsis is always first line therapy before initiating immunosuppressive treatment. Mucosal healing is the goal in the presence of proctitis. Whereas antibiotics and thiopurines have a role as adjunctive treatments in pCD, anti-tumour necrosis factor (anti-TNF) is the current gold standard. The efficacy of infliximab is best documented although adalimumab and certolizumab pegol are moderately effective. Oral tacrolimus could be used in patients failing anti-TNF therapy. Definite surgical repair is only of consideration in the absence of luminal inflammation. CONCLUSIONS: Based on a multidisciplinary approach, items relevant for fistula management were identified and algorithms on diagnosis and treatment of pCD were developed. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Authors: Balakrishnan S Ramakrishna; Govind K Makharia; Vineet Ahuja; Uday C Ghoshal; Venkataraman Jayanthi; Benjamin Perakath; Philip Abraham; Deepak K Bhasin; Shobna J Bhatia; Gourdas Choudhuri; Sunil Dadhich; Devendra Desai; Bhaba Dev Goswami; Sanjeev K Issar; Ajay K Jain; Rakesh Kochhar; Goundappa Loganathan; Sri Prakash Misra; C Ganesh Pai; Sujoy Pal; Mathew Philip; Anna Pulimood; Amarender S Puri; Gautam Ray; Shivaram P Singh; Ajit Sood; Venkatraman Subramanian Journal: Indian J Gastroenterol Date: 2015-03-14