Rectal Endoscopic Ultrasound in the Management of Rectal and Perianal Complaints of Crohn's Disease Patients

Abstract

Background: Rectal and perianal complaints are frequent among Crohn's disease (CD) pts. Rectal endoscopic ultrasound (EUS) is useful in assessing rectal and perianal disease. However, it appears to be underutilized in CD pts. Furthermore, it has been suggested that it should be combined with another method of assessment (exam under anesthesia; EUA) for better results. We report our experience in utilizing EUS as the initial study to assess and manage perianal and rectal complaints among pts with Crohn's disease. Methods: CD pts who underwent rectal EUS were included. Complaints / indications included pain, urgency, fecal incontinence, discharge and suspected fistula, abnormal digital rectal exam, follow up of a previous exam or combination of the above. Management was based solely on EUS findings. Results: Between January 2006 and November 2006 31 CD pts (20 F and 11 M) underwent 36 EUS exam. Indications were: suspected fistula and / or abscess (20), follow up of fistula post treatment (5), rectal pain (7), fecal incontinence and / or urgency in absence of mucosal disease (4). Among pts with suspected fistula and / or abscess, 5 had one fistula and 4 had multiple fistulas (2 rectovaginal and the rest perianal and perirectal), 4 had associated abscesses / septic process and 7 had no fistula or abscess. Treatment based on findings included addition of immunomodulators and / or infliximab in 7, referral for EUA and draining +/- seton placement in addition to medical therapy in 4, observation and reassurance in 11. None required additional assessment beyond what was determined on EUS findings. Among the 5 pts who had repeated EUS for f/u of Rx, 3 had resolution of fistula tract, 1 had a new abscess and 1 had persistent symptomatic fistula (findings were confirmed by EUA). Among pts with persistent rectal pain despite therapy for presumed causes (2 with rectal stricture, 3 with internal hemorrhoids and 2 with suspected fissures) EUS identified a fistula and / or a septic process in 4 pts (1 in pt with stricture, 2 in pts with hemorrhoids and 1 in pt with presumed fissure). Among pts with fecal incontinence and / or urgency in absence of mucosal disease 1 was found to have a complex perirectal fistula and 1 had significant sphincter disruption. Interestingly, mild external sphincter disruption in this cohort was reported in 11 pts (35%). Conclusion: EUS should be considered in all Crohn's disease patients with rectal and perianal complaints. It is complementary to mucosal examination in those patients and can lead to significant changes in the management plan. Furthermore, EUS may be used alone to guide and follow up medical and surgical therapy.