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BMC Proceedings Apr 2024Complex perianal fistula is a common complication of Crohn's disease (CD) which leads to negative impact on patient's quality of life. Successful management of the...
Complex perianal fistula is a common complication of Crohn's disease (CD) which leads to negative impact on patient's quality of life. Successful management of the disease requires a multidisciplinary approach, including a gastroenterologist and a colorectal surgeon, applying combined surgical and medical therapy. One of frequently practiced surgical procedures is seton placement in the fistula tract, which is used to control perianal sepsis and drain the fistula, while preventing recurrent abscess formation.Darvadstrocel, a suspension of expanded, allogeneic, adipose-derived, mesenchymal stem cells, is safe and effective for treatment-refractory complex perianal fistulas in patients with Crohn's disease. Following approval of darvadstrocel, the INSPIRE registry is being conducted in order to evaluate long-term safety and effectiveness of the drug on a large, heterogenous population.An online expert meeting was held from March 20 to March 30, 2023, which provided relevant insights into the decision-making process regarding seton use and obtained feedback on the first experiences with darvadstrocel. The aim of this article is to present the perspectives from gastroenterologists and colorectal surgeons practicing in Czechia, Hungary, Israel, Lithuania, Serbia, and Slovenia in topics such as diagnosis and treatment options for patients with complex Crohn's perianal fistulas (CPF), specifically focusing on the use of setons and darvadstrocel.During this virtual session, unavailability of comprehensive data on safety and efficacy of available treatment procedures was emphasized as an important obstacle towards development of standardized recommendations and improvement of outcomes in treatment of (CPF). Furthermore, achieving consensus in seton use, duration of its placement, and frequency of change is recognized as one of CPF treatments major challenges. Despite these issues, it is important to promote better understanding and treatment of complex perianal fistulas in order to improve the quality of life of those affected by this condition.
PubMed: 38658942
DOI: 10.1186/s12919-024-00291-4 -
Clinical and Experimental Immunology Jun 2024Patients with very early-onset inflammatory bowel disease (VEO-IBD) may present because of underlying monogenic inborn errors of immunity (IEI). Strong differences have...
Patients with very early-onset inflammatory bowel disease (VEO-IBD) may present because of underlying monogenic inborn errors of immunity (IEI). Strong differences have been observed in the causes of monogenic IBD among ethnic populations. This multicenter study was carried out on 16 Iranian patients with VEO-IBD. We reviewed clinical and basic immunologic evaluation including flow cytometry and immunoglobulin levels. All patients underwent clinical whole exome sequencing (WES). Sixteen patients (8 females and 8 males) with a median age of 43.5 months were enrolled. The median age at the onset of symptoms was 4 months. Most patients (12, 75%) had consanguineous parents. Chronic non-bloody diarrhea (13, 81.3%) and perianal diseases including perianal abscess (6, 37.5%), anal fissure (6, 37.5%), or anal fistula (2, 12.5%) were the most common manifestations. WES identified a spectrum of genetic variants in 13 patients (81.3%): IL10RB (6, 37.5%), MVK (3, 18.8%), and CASP8, SLC35C1, G6PC3, and IKBKB in 1 patient, respectively. In 3 patients (18.7%), no variant was identified. Flow cytometry identified a spectrum of abnormalities that helped to assess the evidence of genetic diagnosis. At the end of the survey, 3 (18.8%) patients were deceased. This high rate of monogenic defects with a broad spectrum of genes reiterates the importance of investigating IEI in patients with infantile-onset IBD.
Topics: Humans; Male; Female; Iran; Inflammatory Bowel Diseases; Child, Preschool; Exome Sequencing; Infant; Age of Onset; Child; Genetic Testing; Cohort Studies; Mutation; I-kappa B Kinase; Consanguinity; Receptors, Interleukin-10
PubMed: 38651248
DOI: 10.1093/cei/uxae037 -
Cureus Mar 2024There is limited data on the pathogenic microorganisms associated with anorectal abscesses. The purpose of this study was to retrospectively analyze the types and...
OBJECTIVE
There is limited data on the pathogenic microorganisms associated with anorectal abscesses. The purpose of this study was to retrospectively analyze the types and quantities of pathogenic microorganisms in the pus cultures of patients with anorectal abscesses and to explore the correlation between pathogenic microorganisms and types of anorectal abscesses.
METHODS
A retrospective analysis was conducted on the microbiological data of 517 inpatient surgical patients with anorectal abscesses treated at a single center from January 2017 to December 2021. Chi-square tests were used to analyze whether there were differences in the types and quantities of pathogenic microorganisms among different types of anorectal abscesses.
RESULTS
Among the 517 patients, the mean age was 38.5 years, with an average duration of illness of 7.4 days. Of these, 440 (85.1%) were male and 77 (14.9%) were female. The types of anorectal abscesses included perianal abscesses (54 cases, 10.4%), intersphincteric abscesses (253 cases, 48.9%), ischiorectal abscesses (129 cases, 25.0%), deep posterior anal space (DPAS) abscesses (26 cases, 5.0%), supra-levator abscesses (10 cases, 1.9%), and horseshoe abscesses (45 cases, 8.7%). A total of 23 different microorganisms were cultured from the 517 pus specimens. The most common microorganism was Escherichia coli (323 cases, 62.5%), followed by Klebsiella pneumoniae (77 cases, 14.9%), Bacteroides fragilis (nine cases, 1.7%), Pseudomonas aeruginosa (eight cases, 1.5%), and Staphylococcus aureus (seven cases, 1.4%). Additionally, no microorganisms were cultured from 58 (11.2%) pus specimens. Nine patients (1.7%) were admitted with concomitant necrotizing fasciitis. Among the nine cases of concurrent necrotizing fasciitis, E. coli, K. pneumoniae, and S. aureus were cultured in six (66.7%), two (22.2%), and one (11.1%) case, respectively. Chi-square tests revealed no significant differences in the types and quantities of pathogenic microorganisms among different types of anorectal abscesses (P > 0.05).
CONCLUSION
This study provides a large sample of pus culture microbiological data from patients with anorectal abscesses. Regardless of whether it is a simple anorectal abscess or concurrent necrotizing fasciitis, E. coli was the most common microorganism cultured from the pus of patients with anorectal abscesses. Other common microorganisms include K. pneumoniae, B. fragilis, and S. aureus. These results provide evidence for the precise antibiotic treatment of anorectal abscesses. Additionally, there were no differences in the types and quantities of pathogenic microorganisms among different types of anorectal abscesses.
PubMed: 38646406
DOI: 10.7759/cureus.56504 -
Journal of Hematology Apr 2024Anorectal infections in neutropenic leukemia patients are a significant and potentially life-threatening complication. The pathogenesis of this condition is not entirely... (Review)
Review
Anorectal infections in neutropenic leukemia patients are a significant and potentially life-threatening complication. The pathogenesis of this condition is not entirely understood and believed to be multifactorial, including mucosal injury as a result of cytotoxic drugs, profound neutropenia and impaired host defense. Establishing an early diagnosis is key and often made clinically on the basis of signs and symptoms, but also from imaging studies demonstrating perianal inflammation or fluid collection. The management of anorectal infections in neutropenic leukemia patients is not straightforward, as there are no well-conducted studies on this entity. This review seeks to provide a framework into the pathophysiology and clinical presentation of anorectal infections in neutropenic leukemia patients, propose a diagnostic approach and to discuss controversies in the management of this condition.
PubMed: 38644983
DOI: 10.14740/jh1251 -
Cureus Mar 2024Complications can arise secondary to anorectal suppurative diseases, with infections spreading along the extraperitoneal space, such as the peri-vesical, prevesical,...
Complications can arise secondary to anorectal suppurative diseases, with infections spreading along the extraperitoneal space, such as the peri-vesical, prevesical, pre-sacral, and pararectal spaces, resulting in abscesses at remote sites, which can make diagnosis more challenging. Due to the absence of peritonitis symptoms, there is a delay in presentation among such patients. Comprehending the intricacies of these areas and the way infection can spread within them is crucial for promptly identifying and effectively draining the extraperitoneal abscess. We present a case series of six patients with a mean age of 45, all males. A total of three patients had undergone incision and drainage after being diagnosed with anorectal suppurative disease and remained symptomatic after the initial surgical intervention of incision and drainage. Two patients initially diagnosed with anterior abdominal abscesses patients, after being treated with incision and drainage, continued to have purulent discharge from the drainage site. Finally, the last patient continued to present with perianal pain after an open hemorrhoidectomy. CT scans of all six patients showed collections in the extraperitoneal spaces correlated with the observed complications. To deepen our understanding of pelvic extraperitoneal spaces, cadaver dissections were conducted and compared with CT images. Through cadaver dissections and CT imaging, the study provides insights into the anatomy and interconnections of pelvic extraperitoneal spaces, emphasizing the importance of early CT scans for diagnosis. Understanding these intricate anatomical structures is essential for accurate diagnosis and efficient and effective treatment. Timely diagnosis is vital to prevent prolonged illness and reduce the risk of complications and mortality. The importance of early CT scans in suspected patients is underscored, which is highly important to expedite appropriate actions.
PubMed: 38618365
DOI: 10.7759/cureus.56149 -
Cureus Mar 2024Crohn's disease (CD) is an inflammatory condition affecting the gastrointestinal tract, often leading to persistent inflammation in various parts, notably the terminal...
Crohn's disease (CD) is an inflammatory condition affecting the gastrointestinal tract, often leading to persistent inflammation in various parts, notably the terminal ileum and colon. Clinical manifestations of CD can become complex due to complications like strictures, fistulas, and perianal abscesses. The disease typically exhibits transmural inflammation and skip lesions, where unaffected areas alternate with affected ones. Treatment goals focus on achieving disease remission and preventing complications that may require surgical intervention. Surgery becomes crucial in managing complications such as Crohn's strictures and perforations. Here, we describe a challenging case involving a young woman who underwent surgery for abdominal abscess and with Crohn's stricture and fistula.
PubMed: 38606263
DOI: 10.7759/cureus.55993 -
Cureus Mar 2024Infantile inflammatory bowel disease (IBD) is a very rare subgroup of IBD that develops in children younger than two years with genetic susceptibility, especially in...
Infantile inflammatory bowel disease (IBD) is a very rare subgroup of IBD that develops in children younger than two years with genetic susceptibility, especially in those with monogenic defects. This type, when compared with IBD in older children, is more resistant to conventional medical treatment and presents with more complications that require more surgical interventions. Our patient is a male with first-degree consanguineous parents. He was 16 months old when he presented with multiple perianal fistulas, fissures, abscesses, diarrhea, fever, and failure to thrive. He underwent a protective double-barrel ileostomy and surgical repair of the perianal disease. Crohn's disease was confirmed after endoscopy and biopsy. A genetic workup was done and revealed receptor-interacting protein kinase 1 () mutations. Conventional pediatric IBD treatment was initiated after surgery, including tumor necrosis factor antagonist adalimumab 40 mg subcutaneously weekly for five months. Despite treatment, he presented with dysuria and a colovesical fistula. The patient underwent secondary surgical repair.
PubMed: 38586767
DOI: 10.7759/cureus.55708 -
Abdominal Radiology (New York) Apr 2024Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and... (Review)
Review
Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and physiology of the anorectal region and has been used in pre-and post-operative settings of anorectal pathologies. EAUS is not only useful in the evaluation of benign pathologies but also in loco-regional staging of anal and rectal tumors. EAUS has several advantages over MRI, including reduced cost, better patient tolerance, and improved scope of application in patients with contraindications to MRI. Despite its benefits, EAUS is not widely performed in many centers across the globe. This article aims to educate radiologists, trainees, and surgeons about the indications, contraindications, patient preparation, imaging technique, and findings of EAUS. We will also highlight the technical difficulties, diagnostic challenges, and procedural complications encountered during EAUS, along with a comparative analysis of EAUS with other imaging approaches.
PubMed: 38580791
DOI: 10.1007/s00261-024-04300-0 -
World Journal of Stem Cells Mar 2024Stem cell transplantation is a promising therapeutic option for curing perianal fistula in Crohn's disease (CD). Anti-tumor necrotic factor (TNF) therapy combined with...
BACKGROUND
Stem cell transplantation is a promising therapeutic option for curing perianal fistula in Crohn's disease (CD). Anti-tumor necrotic factor (TNF) therapy combined with drainage procedure is effective as well. However, previous studies are limited to proving whether the combination treatment of biologics and stem cell transplantation improves the effect of fistula closure.
AIM
This study aimed to evaluate the long-term outcomes of stem cell transplantation and compare Crohn's perianal fistula (CPF) closure rates after stem cell transplantation with and without anti-TNF therapy, and to identify the factors affecting CPF closure and recurrence.
METHODS
The patients with CD who underwent stem cell transplantation for treating perianal fistula in our institution between Jun 2014 and December 2022 were enrolled. Clinical data were compared according to anti-TNF therapy and CPF closure.
RESULTS
A total of 65 patients were included. The median age of females was 26 years (range: 21-31) and that of males was 29 (44.6%). The mean follow-up duration was 65.88 ± 32.65 months, and complete closure was observed in 50 (76.9%) patients. The closure rates were similar after stem cell transplantation with and without anti-TNF therapy (66.7% 81.6% at 3 year, = 0.098). The patients with fistula closure had short fistulous tract and infrequent proctitis and anorectal stricture ( = 0.027, 0.002, and 0.008, respectively). Clinical factors such as complexity, number of fistulas, presence of concurrent abscess, and medication were not significant for closure. The cumulative 1-, 2-, and 3-year closure rates were 66.2%, 73.8%, and 75.4%, respectively.
CONCLUSION
Anti-TNF therapy does not increase CPF closure rates in patients with stem cell transplantation. However, both refractory and non-refractory CPF have similar closure rates after additional anti-TNF therapy. Fistulous tract length, proctitis, and anal stricture are risk factors for non-closure in patients with CPF after stem cell transplantation.
PubMed: 38577230
DOI: 10.4252/wjsc.v16.i3.257 -
The Korean Journal of Internal Medicine May 2024A poor prognostic factor for Crohn's disease (CD) includes perianal fistulizing disease, including perianal fistula and/or perianal abscess. Currently, a tool to assess...
BACKGROUND/AIMS
A poor prognostic factor for Crohn's disease (CD) includes perianal fistulizing disease, including perianal fistula and/or perianal abscess. Currently, a tool to assess perianal symptoms in patients with CD remains nonexistent. This study aimed to develop a perianal fistulizing disease self-screening questionnaire for patients with CD.
METHODS
This prospective pilot study was conducted at three tertiary referral centers between January 2019 and May 2020. We formulated questions on perianal symptoms, including tenesmus, anal discharge, bleeding, pain, and heat. A 4-point Likert scale was used to rate each question. Patients with CD completed a questionnaire and underwent pelvic magnetic resonance imaging (MRI).
RESULTS
Overall, 93 patients were enrolled, with 51 (54.8%) diagnosed with perianal fistulizing disease, as determined by pelvic MRI. The Spearman correlation findings demonstrated that anal pain (p = 0.450, p < 0.001) and anal discharge (p = 0.556, p < 0.001) were the symptoms that most significantly correlated with perianal disease. For anal pain and discharge, the area under the receiver operating characteristic curve of the scores was significantly higher than that of the combined score for all five symptoms (0.855 vs. 0.794, DeLong's test p = 0.04). For the two symptoms combined, the sensitivity, specificity, and positive predictive and negative predictive values were 88.2, 73.8, 80.4, and 83.8%, respectively, with 81.7% accuracy for detecting perianal fistulizing disease.
CONCLUSION
This study indicates that simple questions regarding anal pain and discharge can help accurately identify the presence of perianal fistulizing disease in patients with CD.
Topics: Humans; Crohn Disease; Male; Female; Adult; Rectal Fistula; Prospective Studies; Pilot Projects; Magnetic Resonance Imaging; Middle Aged; Predictive Value of Tests; Surveys and Questionnaires; Young Adult; Reproducibility of Results
PubMed: 38576234
DOI: 10.3904/kjim.2023.410