Thread by @mjayoushe

@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty 1/ 27 yo F, crohns colitis on AZA, presents w 2wk perianal pain. One week ago a “boil” developed adjacent to the anus, painful to touch and draining cloudy fluid. PE: Perianal fistulous opening tender & draining pus on palpation. What is the next best step ? #B2B

@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty 2/Recap #Crohns:
📌Transmural inflammation involving any part of GIT
📌B for Phenotypes: inflammatory/stricturing/penetrating
📌L for location: UGI,SB,Colon
📌Penetrating Behaviors:
Fistulae
Perforations
Intra-abdominal abscesses(IAA)

recall this #B2B MTL classification table👇🏼

@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty 3/♦️p->Perianal ds in CD
♦️Can occur w any B&L
♦️May be initial manif in ~10%
♦️Can be isolated(no luminal dis)
♦️Affect up to 1/3 of CD pts
♦️Incidence cld be ⬇️w⬆️use of biologics @sang_hyoung @EdwardLoftus2 pubmed.ncbi.nlm.nih.gov/30346531/

♦️One of most challenging manif for pts+MDs

@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty @sang_hyoung @EdwardLoftus2 4/Perianal #Fistulas in CD

📌Simple fistula:
♦️Below sphincter(confined to anal canal)
♦️Single external opening
♦️❌abscess❌stricture ❌🔥

📌Complex fistula=Everything else:
♦️>1 external openings
♦️ +Abscess/Stricture/Proctitis
Active proctitis→⬇️fistula healing⬆️recurrence

@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty @sang_hyoung @EdwardLoftus2 5/Perianal Fistula Dx

♦️ ✅ Fistula type & abscess
♦️ One imaging + EUA

▶️ MRI pelvis ++

▶️ EUS if no rectal stenosis, if expertise

▶️ EUA: For abscess drainage+seton

▶️Repeat MRI can be considered before d/c Seton

#B2BPearl: What’s a #SETON ?? 👇🏼👇🏼

@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty @sang_hyoung @EdwardLoftus2 6/ Perianal #Fistula Rx goals🎯 + strategies: Medical+CRS

1️⃣Control sepsis

2️⃣Treat underlying inflam/stricture

3️⃣Close fistula (not always possible)

4️⃣Prevent abscess recurrence

5️⃣Improve QOL

@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty @sang_hyoung @EdwardLoftus2 Perianal #Fistula Rx @AmerGastroAssn

1️⃣Abscess drainage+seton
2️⃣Abx:Cipro+Metro
🔹If abscess,along w I/D
🔹#B2BPearl:Long term Cipro use:⬇️fistula drainage,⬆️ closure,⬇️abscess recurrence on TNFi
3️⃣1st line:IFX+IMM
🔹#B2BPearl: ⬆️IFX trough levels may be needed to close fistula

@MondayNightIBD @SobiaMujtabaMD @SchwartzbergMD @DCharabaty @sang_hyoung @EdwardLoftus2 @AmerGastroAssn 8/ For Med Refractory fistula ✂️ 🔪

📍Fistulotomy,if simple fistula

📍Fibrin glue,Limited efficacy

📍Mucosal Advancement Flap, After control of proctitis

📍Diverting Ostomy,if severe perianal sepsis/fistula

📍LIFT

📍NKOTB: Mesenchymal Stem Cell doi.org/10.1053/j.gast…