Shirley Cohen-Mekelburg, MD, on Penetrating and Stricturing Crohn's Disease
Dr Cohen-Mekelburg recaps the key takeaways from her presentation at the AIBD regional meeting in Detroit on managing penetrating and stricturing Crohn's disease and perianal disease.
Shirley Cohen-Mekelburg, MD, is an assistant professor of internal medicine at the University of Michigan Medical School and director of the IBD Clinic at VA Ann Arbor Healthcare System.
TRANSCRIPT:
Hi everyone. My name is Shirley Cohen Mekelburg, and I'm a gastroenterologist at the University of Michigan. I am here at the AIBD Regionals Conference in Detroit, Michigan, where we've been discussing fistulizing and stricturing Crohn's disease.
Here are the key takeaways. So Crohn's disease is a progressive disease that usually starts with subclinical inflammation. Patients experience relapsing and remitting flares. But in the background of this, we see progression of disease, including bowel damage such as strictures and fistulas, and many patients eventually require surgery. So let's discuss Crohn's disease strictures, and then Crohn's disease fistulas.
So Crohn's disease strictures are narrowings that present in the intestine. They're usually comprised of both an inflammatory component and a fibrotic component. And so when patients present with obstructive symptoms, the main question is how much of their disease is driven by inflammation versus fibrosis? As this will impact our treatment decisions in patients who have an inflammatory component, which can often be differentiated by imaging, we will treat them with medical therapy including biologics such as antitumor necrosis factor agents, or anti-IL-23s.
However, in patients where there is more of a fibrotic component, we will consider a mechanical treatment, such as an endoscopic balloon dilation or surgery. These decisions can be made based on the extent of a stricture, the number of strictures if it's within the reach of a colonoscope, as well as the patient's symptoms.
Moving on to fistulizing disease, the most common type of fistulizing disease in Crohn's is perianal fistulas. These are tracts that can develop in the perianal region and can be associated with complications such as abscesses. In the management of these patients, it's first important to really have a comprehensive evaluation of these fistulas, which can be done by a combination of modalities, including an exam under anesthesia, cross-sectional imaging, as well as colonoscopy or flexible sigmoidoscopy, to evaluate for any rectal inflammation. The medical treatment of patients with perianal fistulas includes biologic or small molecule treatment, usually with a combination anti-TNF agent and potentially an immunomodulator or other more advanced therapies if this therapy has failed or if the patient's already had experience with this.
Beyond this, what's most important when treating patients with perianal fistulas is to have a multidisciplinary approach. In general, we can classify these fistulas as simple if they involve one tract and are not associated, for example, with any abscesses, in which case medical treatment might be sufficient. However, the majority of these fistulas can be complex and require both a surgical approach, including seton placement and medical treatment. And with that, we have a summary of strictures and fistulas and IBD.
