Perianal Disease

Crohn’s disease is a chronic inflammatory bowel disease that can cause inflammation in any part of the digestive system, including the anus. Perianal Crohn’s disease is a type of Crohn’s disease that affects the anus and rectum. It can occur on its own or along with other forms of Crohn’s disease that affect other parts of the digestive system. Perianal Crohn’s is present in up to a fifth of people with Crohn’s disease.

Perianal Crohn’s disease may manifest in several ways:

Fistulas (channels that connect one organ to another).
Abscesses (pockets of infected pus).
Rectal strictures (narrowing of the rectal or anal opening due to scar tissue).
Ulcers (open sores).
Skin tags.
Fissures (tears in the lining of the anal canal).

Perianal Fistulas

An anal fistula is a small tunnel that forms between the end of the bowel (anal canal) and the skin near the anus. Anal fistulas are a common complication of Crohn’s disease, a type of inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal tract. Crohn’s disease can cause inflammation in the anal area, which can lead to the formation of an abscess (a pocket of pus). If the abscess bursts, it can create a fistula, which is a tunnel that connects the abscess to the anus or nearby skin.

Treatment options for an anal fistula in Crohn’s disease include:

Medications: anti-inflammatory medications such as corticosteroids, immunomodulators, and biologic therapy can help to reduce inflammation and promote healing.
Surgery: surgery may be necessary to drain an abscess, or to remove the fistula.
Seton Drainage: a seton is a small piece of surgical thread that is placed through the fistula tract to keep it open and allow it to heal.

Abscesses

Perianal Crohn’s abscesses are pockets of pus that form in the intestinal wall due to infection from bacteria. They can occur in people with Crohn’s disease, a chronic inflammatory disease that affects the digestive system. Abscesses can often lead to the development of fistulas, which are channels that connect one organ to another. Symptoms of perianal Crohn’s abscesses may include pain and swelling around the anus, anal bleeding, and the passing of pus or mucus. If left untreated, abscesses can become serious and may require surgical treatment. It is important to consult a doctor if you experience any symptoms of an abscess.

Anal Stricture

Anal stricture is a condition in which the anus (the opening at the end of the digestive tract through which bowel movements are expelled) becomes narrowed due to scar tissue caused by chronic inflammation. This can cause the area to become partially or fully blocked, slowing or stopping the movement of stool. If the anus becomes completely blocked, it can be life-threatening and often requires surgery to correct. Symptoms of anal stricture may include pain and difficulty passing stools, bleeding from the anus, and a feeling of incomplete bowel movements. Treatment for anal stricture may include medications to reduce inflammation, dietary changes to soften stools, and in severe cases, surgery to widen the anus.

Fissures

An anal fissure is a tear or crack in the lining of the anus. It can cause pain and bleeding during bowel movements. Anal fissures are common in people with Crohn’s disease, as chronic inflammation in the digestive system can lead to the development of ulcers and tears in the anus. Other symptoms of anal fissures may include itching, burning, and a feeling of pressure or tightness in the anus. Anal fissures can often be treated with medications, such as topical creams or ointments, to reduce inflammation and promote healing. In some cases, surgery may be necessary to repair the fissure. It is important to speak with a healthcare professional for proper diagnosis and treatment of anal fissures.

Hemorrhoids

Hemorrhoids are swollen veins in the lower rectum or anus. They are a common problem that can occur in anyone, but people with Crohn’s disease may be more likely to develop hemorrhoids due to chronic diarrhea and constipation, which can put extra strain on the veins in the anus. Symptoms of hemorrhoids can include rectal bleeding, itching, and pain or discomfort during bowel movements. In some cases, people with Crohn’s disease may also develop external hemorrhoids, which are swollen veins outside of the anus and can cause pain and swelling.

Treatment for hemorrhoids in people with Crohn’s disease may involve over-the-counter creams or ointments to reduce swelling and discomfort, as well as increasing fiber in the diet to reduce constipation. In severe cases, a doctor may recommend more invasive treatment such as rubber band ligation or surgical removal of the hemorrhoids. It is important to speak with a healthcare provider if you are experiencing symptoms of hemorrhoids, as they can help determine the best treatment plan for you.

Anal skin tags

One complication of perianal Crohn’s disease is the formation of skin tags, which are small, fleshy growths around the anus. These skin tags can be a result of chronic inflammation and scarring in the area.

Symptoms

Symptoms of perianal Crohn’s may include:

Pain, discomfort or itching around the anus.
Bleeding or discharge from the anus.
Feeling of urgency to have a bowel movement or incontinence.
Painful lump(s) around the anus.
Drainage of pus or blood from the fistula.
Constipation or diarrhea.
Skin irritation or redness around the anus.

Evaluation

Perianal disease is usually evaluated by a gastroenterologist or colorectal surgeon, who will perform a physical examination and assess your medical history. The doctor may also order tests to determine the severity and extent of the disease, including:

Medical history and physical exam.
Digital rectal examination: this involves the doctor inserting a finger into the rectum to feel for abnormalities or swelling.
Anoscopy: this is a procedure in which the doctor uses a small, lighted instrument called an anoscope to examine the anus and lower rectum.
Colonoscopy: this is a procedure in which the doctor uses a flexible, lighted instrument called a colonoscope to examine the inside of the colon and rectum.
CT scan or MRI: these are imaging tests that use x-rays or magnetic fields to create detailed pictures of the inside of the body. An MRI can be helpful in looking at perianal fistulas. This test can show your doctor where the fistula is and if you have an abscess too.
Laboratory tests: the doctor may also order blood tests or stool tests to help diagnose perianal disease.
Sometimes, a healthcare provider might recommend having a special test called an examination under anesthesia. This means you will be put to sleep for a short time so the provider can take a closer look at your anus and rectum. They might use their fingers or special tools to feel around and see where the fistula goes.

It is important to see a healthcare provider if you have any symptoms of perianal Crohn’s disease, as early treatment can help prevent complications and improve quality of life.

Treatment Overview

There are several treatment options for perianal Crohn’s disease. The type of treatment used may depend on the severity of the disease and the specific symptoms and complications being experienced. Some common treatments include:

Medications: it is important to work closely with a healthcare provider to determine the best treatment plan for perianal Crohn’s disease. Regular check-ups and follow-up care can help ensure that the disease is well-controlled and prevent complications from occurring.
- Anti-inflammatory drugs, such as corticosteroids, may be used to reduce inflammation and improve symptoms.
- Antibiotics for treatment of abscesses.
- Biologics, which are medications that target specific immune system proteins, may also be used to reduce inflammation. TNF inhibitors are a type of medication that can be used to treat perianal Crohn’s disease. TNF stands for tumor necrosis factor, which is a chemical that helps to regulate inflammation in the body. In people with Crohn’s disease, the body produces too much TNF, which can lead to inflammation in the digestive system. TNF inhibitors work by blocking the effects of TNF and reducing inflammation in the body. These medications are usually given by injection or infusion (through a vein) and are usually taken every few weeks. Some common TNF inhibitors include adalimumab, certolizumab, and infliximab. TNF inhibitors can be effective in reducing inflammation and symptoms in people with perianal Crohn’s disease, but they can also have side effects, such as infections and an increased risk of certain types of cancer. It is important to talk to your doctor about the benefits and risks of TNF inhibitors and to follow their instructions for taking these medications.
- Topical treatments: creams or ointments applied directly to the skin around the anus may help reduce symptoms and improve healing.
- Diet and lifestyle changes: eating a healthy, well-balanced diet and avoiding foods that irritate the intestine may help reduce symptoms and prevent complications. Drinking plenty of fluids and getting regular exercise may also be helpful.

Surgery: in some cases, surgery may be necessary to remove infected or damaged tissue, repair fistulas or abscesses, or widen strictures. There are several types of surgery that may be used to treat perianal Crohn’s disease, including:
- Fistulotomy: this procedure involves cutting open and draining the fistula. It may be done using a local anesthetic or general anesthetic.
- Abscess drainage: if an abscess has formed, it may need to be drained to help it heal. This can be done through a small incision or with the use of a catheter.
- A doctor may use a seton, which is a thin rubber drain that they place in the fistula to keep it open, preventing further abscesses from forming. Doctors usually remove setons once medical treatment has begun to manage a person’s Crohn’s disease.
- Strictureplasty: this procedure involves widening the narrow area of the intestine (stricture) to allow for easier passage of stools. It may be done using a local anesthetic or general anesthetic.
- Anal sphincter repair: if the muscles that control bowel movements (anal sphincters) are damaged or weakened, surgery may be needed to repair them. This may be done using a local anesthetic or general anesthetic.
- Colectomy: in severe cases of Crohn’s disease, a portion of the colon may need to be removed. This procedure is called a colectomy and may be done using a local anesthetic or general anesthetic.
- If the rectum or anus is severely damaged, a person with perianal Crohn’s may need to have a diverting ostomy. This is a surgical procedure where a part of the intestine is brought to the surface of the abdomen and a bag is attached to collect stool. This can help the rectum or anus heal and can also be used to treat severe cases of perianal Crohn’s that don’t get better with other treatments.

It is important to discuss the risks and benefits of surgery with your doctor to determine the best treatment option for your individual situation.

FAQs

What are the common treatments for perianal disease in Crohn's disease?

Treatment for perianal disease in Crohn’s disease may include medications to reduce inflammation, such as corticosteroids or biologics, as well as surgery to remove any abscesses or fistulas.

How common is perianal Crohn's disease?

Perianal Crohn’s disease is a form of Crohn’s disease which causes inflammation around the anus. It can occur on its own or at the same time as other forms of Crohn’s disease which cause inflammation in other parts of the digestive system. Perianal Crohn’s affects up to a third of people with Crohn’s disease however published reports vary from nearly 4% to 80% depending on the population studied. Perianal disease is more common in people with Crohn’s disease than ulcerative colitis.

How is perianal disease evaluated?

Digital rectal examination: This involves the doctor inserting a finger into the rectum to feel for abnormalities or swelling.
Anoscopy: This is a procedure in which the doctor uses a small, lighted instrument called an anoscope to examine the anus and lower rectum.
Colonoscopy: This is a procedure in which the doctor uses a flexible, lighted instrument called a colonoscope to examine the inside of the colon and rectum.
CT scan or MRI: These are imaging tests that use X-rays or magnetic fields to create detailed pictures of the inside of the body. An MRI can be helpful in looking at perianal fistulas. This test can show your doctor where the fistula is and if you have an abscess too.
Laboratory tests: The doctor may also order blood tests or stool tests to help diagnose perianal disease.
Sometimes, a healthcare provider might recommend having a special test called an examination under anesthesia. This means you will be put to sleep for a short time so the provider can take a closer look at your anus and rectum. They might use their fingers or special tools to feel around and see where the fistula goes.

Depending on the results of these tests, the doctor may recommend a treatment plan that may include medications, surgery, or other therapies to manage the symptoms and prevent complications of perianal disease.

How can I manage symptoms of perianal disease in Crohn's disease?

Here are some tips for managing perianal disease in Crohn’s disease:

Keep track of your symptoms and any potential triggers. This can help you identify patterns and find ways to prevent or manage your symptoms.
Exercise regularly. Physical activity can help reduce stress and improve your overall health.
Avoid smoking, as this can worsen your symptoms.
Manage stress using techniques such as breathing exercises, yoga, or cognitive behavioral therapy.
Use a moist towel instead of toilet tissue to reduce irritation to the anal area.
Shower using a hand shower or use a perianal cleansing product, such as Balneol.
Before going to bed, apply an ointment to protect the skin around the anus, such as Vitamin A&D ointment or Desitin.
Bathe in warm salt water to soothe any anal pain or tenderness.
Carry an emergency kit containing items such as toilet tissue, spare underwear, and baby wipes to help ease anxiety.
Find a local or online support group that can help provide a network of people going through similar experiences. Support groups can be a great source of information, encouragement, and emotional support.