Perianal Fistulizing Crohn's Disease Research Articles

Evaluation of an MRI-based score of disease activity in perianal fistulizing Crohn's disease

To evaluate a magnetic resonance imaging (MRI)-based score of disease severity for perianal fistulizing Crohn's disease (CD), 16 patients with perianal fistulizing CD underwent 1.5-T MRI before and after infliximab therapy. MRI scores, Perianal Disease Activity Index (PDAI) and C-reactive protein (CRP) were calculated, and fistula drainage was assessed. These items were compared for responders and nonresponders. After therapy, PDAI values and CRP values decreased significantly in responders, but there were no significant differences in the MRI scores. In all responders, MRI findings were indicative of persisting active inflammation. In these patients, a relapse rate of 57% was seen.

Clinical and Radiological Response to Anti-TNF Alpha Treatment for Perianal Fistulizing Crohn's Disease in One Institution in Pediatric Patients

Clinical and Radiological Response to Anti-TNF Alpha Treatment for Perianal Fistulizing Crohn's Disease in One Institution in Pediatric Patients

Efficacy and safety of certolizumab pegol in an unselected crohnʼs disease population

Certolizumab pegol (Cimzia, CZP) was approved for the treatment of Crohn's disease (CD) patients in 2007 in Switzerland as the first country worldwide. This prospective phase IV study aimed to evaluate the efficacy and safety of CZP over 26 weeks in a multicenter cohort of practice-based patients. Evaluation questionnaires at baseline, week 6, and week 26 were completed by gastroenterologists in hospitals and private practices. Adverse events were evaluated according to World Health Organization (WHO) guidelines. Sixty patients (38F/22M) were included; 53% had complicated disease (stricturing or penetrating), 45% had undergone prior CD-related surgery. All patients had prior exposure to systemic steroids, 96% to immunomodulators, 73% to infliximab, and 43% to adalimumab. A significant decrease of the Harvey-Bradshaw Index (HBI) was observed under CZP therapy (12.2 ± 4.9 at week 0 versus 6.3 ± 4.7 at week 6 and 6.7 ± 5.3 at week 26, both P < 0.001). Response and remission rates were 70% and 40% (week 6) and 67% and 36%, respectively (week 26). The complete perianal fistula closure rate was 36% at week 6 and 55% at week 26. The frequency of adverse drug reactions attributed to CZP was 5%. CZP was continued in 88% of patients beyond week 6 and in 67% beyond week 26. In a population of CD patients with predominantly complicated disease behavior, CZP proved to be effective in induction and maintenance of response and remission. This series provides the first evidence of CZP's effectiveness in perianal fistulizing CD in clinical practice.

Long-Term Monitoring of Infliximab Therapy for Perianal Fistulizing Crohn's Disease by Using Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is used to assess the outcome of infliximab (IFX) therapy in patients with perianal fistulizing Crohn's disease (pfCD). However, few long-term data are available about its efficacy. We assessed 59 patients with pfCD by MRI and clinical evaluation at baseline. Treated patients then received paired clinical and MRI examinations for a median time period of 36 (11-53.3) weeks. Short-, mid-, and long-term effects of therapy, as well as the ability of MRI to predict treatment outcome and need for surgery, were evaluated. Compared with the baseline MRI, the short-term follow-up MRI (n = 29) revealed a reduced number of fistula tracks in 13.8% and in the inflammatory activity in 55.2% of patients, respectively; mid-term MRI (n = 25) in 56% and in 52%, respectively; and long-term MRI (n = 13) in 15.4% and in 31%, respectively. Improvement of pfCD based on MRI results coincided with clinical improvement in 54.7% of the patients. Short-term and mid-term (but not long-term) MRI showed a significant decrease in the activity score. Therapy outcome was worse among patients with persisting fistulas (P = .01), collections (P = .009), and rectal wall involvement (P = .01) in the final MRI. Patients with single-branched fistulas (P < .0001) and collections (P = .006) in their baseline MRI were more likely to undergo surgery. MRI is a useful technique for evaluation of pfCD during the first year of follow-up. In the long-term, the MRI improvement coincides with clinical and endoscopic response to IFX in 50% of the patients.

Anti-TNF and Fistulising Perianal Crohns Disease: Use in Clinical Practice

Perianal fistulas are a major problem of patients with Crohn's disease (CD), and occur in up to 40 % of patients. The treatment of fistulizing perianal CD has recently largely evolved as a result of improvements of pharmacological and surgical approaches and the introduction of anti-TNF treatment. Especially the use of anti-TNF agents in complex or refractory perianal fistulas has been proven as the most effective medical treatment of this difficult to treat disease. Infliximab and adalimumab are the two currently available anti-TNF agents that both have shown significant efficacy in the treatment and sustained remission of perianal fistulizing CD with comparable fistula closure rates. However, despite this treatment a large number of patients have continuous disease activity and high relapsing rates whereas only a small percentage of them have a complete fistula healing. Therefore the optimal outcome is still dependent on a multidisciplinary approach with a close interaction between gastroenterologists and surgeons. The individualised treatment based on anti-TNF agents with the rational combination of antibiotic use, surgery and immunosuppressive therapy is, currently, the suggested treatment in order to achieve remission of a persistent perianal fistula. Large randomised studies are required for the long-term evaluation of the efficacy in modifying the disease course of this combined approach.

Efficacy and safety of certolizumab pegol induction therapy in an unselected Crohnʼs disease population

Switzerland was the first country to approve certolizumab pegol (Cimzia, CZP) for the treatment of patients with moderate to severe Crohn's disease (CD) in September 2007. This phase IV study aimed to evaluate the efficacy and safety of CZP in a Swiss multicenter cohort of practice-based patients. Baseline and Week 6 evaluation questionnaires were sent to all Swiss gastroenterologists in hospitals and private practices. Disease activity was assessed with the Harvey-Bradshaw Index (HBI) and adverse events were evaluated according to WHO guidelines. Fifty patients (31 women, 19 men) were included; 56% had complicated disease (stricture or fistula) and 52% had undergone prior CD-related surgery. All patients had prior exposure to systemic steroids, 96% to immunomodulators, 78% to infliximab, and 50% to adalimumab. A significant decrease in HBI was observed at Week 6 (versus Week 0) following induction therapy with CZP 400 mg subcutaneously at Weeks 0, 2, and 4 (12.6 +/- 4.7 Week 0 versus 6.2 +/- 4.4 Week 6, P < 0.001). Response and remission rates at Week 6 were 54% and 40%, respectively. We identified 8/11 CD patients undergoing a 50% fistula response (P = 0.021). The frequency of adverse drug reactions attributed to CZP was 6%. CZP was continued in 80% of patients beyond Week 6. In a population of CD patients with complicated disease behavior, CZP induced a response and remission in 54% and 40% of patients, respectively. This series provides the first evidence of the effectiveness of CZP in perianal fistulizing CD.

Perianales Fistelleiden bei Morbus Crohn – Biologika und Chirurgie: Ein lohnendes Konzept?

Perianal fistulas and abscesses are a common manifestation in Crohn's disease (CD), seen in about 30 - 40 % of the patients. Often they are combined with CD of the anal canal and occur as a complex system of fistulas. The evaluation of these fistulas can be done with endoscopic ultrasound or magnetic resonance imaging, the conceptual accuracy of both methods is high. There are accepted therapeutic concepts for surgery and for the conventional drug therapy according to the classification of the fistulas. In contrast, the therapeutic regimens for a complex perianal fistulising CD are not convincing, especially not for maintainance therapy. However, several studies about therapy with anti-TNF-alpha antibodies have shown good results while long-time results with other recent anti-TNF-alpha antibodies apart from infliximab are still lacking. In this review article we analyse the current literature and develop a stage-adapted therapy for the use of biologicals and surgery in fistulising perianal CD.

Predicting Factors of Fistula Healing and Clinical Remission After Infliximab-Based Combined Therapy for Perianal Fistulizing Crohn’s Disease

Perianal fistulizing Crohn's disease (PFCD) treatment is based on fistula drainage, antibiotics, immunosuppressant (IS) drugs, and infliximab. Our aim was to study the effectiveness of combination therapy on PFCD and to search for clinical or imaging features associated with the initial complete clinical response and its stability overtime. All patients with PFCD treated in our tertiary center between 2000 and 2005 by infliximab in combination with seton placement and/or IS and evaluated by MRI before treatment were included in the study. Basal clinical and MRI characteristics were recorded. Response to treatment was evaluated after the infliximab induction regiment and at the end of the follow-up. Twenty-six patients were included and followed-up for an average 4.9 years. A complex fistula was present in 69% (18/26 patients) of cases and eight (8/26 patients) had an ano-vaginal fistula. After infliximab induction therapy, 13 patients (50%) achieved a complete clinical response. The initial clinical response was significantly associated with the absence of both, active intestinal disease (54% vs. 8%, P = 0.03) and active proctitis (77% vs. 23%, P = 0.01). No initial MRI characteristics were linked to the initial response. In multivariate analysis, only the presence of active proctitis was associated with the lack of response (P = 0.047). At the end of the follow-up, 42% of the patients remained in clinical remission. No clinical characteristics were associated to sustained response when among long-standing responders two exhibited a normal post-treatment MRI. An initial complete response of PFCD was observed in half of the patients after combined therapy including infliximab that decreased to 42% later on. Complete healing of fistulas on MRI was possible but unusual. The initial response seemed related to the absence of active intestinal disease, especially in the rectum, when the long-term response could not be predicted by the basal characteristics of patients.

Clinical and Radiological Responses after Infliximab Treatment for Perianal Fistulizing Crohn's Disease

Clinical and Radiological Responses after Infliximab Treatment for Perianal Fistulizing Crohn's Disease