Understanding Fistulas and Treatment Options

As you can see from these charts, several types of fistulas can be associated with Perianal Crohn's disease. The type of fistula you have will influence your treatment. It's possible to have multiple fistulas at once, and they can branch out like tree branches, leading to complex fistulas, especially if they involve a large portion of the sphincter muscle.

In the next few pages, you'll find information about various treatments for fistulas, including setons (small rubber band-type sutures looped through the fistula), fistulotomies, FiLaC, biologics, and antibiotic therapy. It's important to be cautious about overzealous procedures, as studies suggest that placing setons during the initial abscess may cause more harm than good.

I highly recommend exploring all treatment options and seeking second opinions before making any decisions about corrective surgeries for fistulas, colon diversion surgery (ostomy), fecal diversion surgery, or a proctectomy. Although some surgeons claim high success rates for these procedures, statistics show that 18% to 33% of people achieve remission, while others may experience worsening conditions and complications.

I am continually adding new information, so please check back often. You can email me at fistulizingcrohns@gmail.com with questions, suggestions, or for support. I would love to share your story on my blog page.

Different types of fistula's in Perianal Crohn's

Submucosal Superficial fistula. The track does not involve any Sphincter muscle.
 Intersphincteric Track crosses the internal sphincter with a Tract to the perianal skin. It does not involve any External anal sphincter muscle.
Transsphincteric- Tracks from the internal opening at the dentate line via the internal and external anal sphincters, and then it ends in the perianal skin or perineum.
Suprasphincteric Tracks superiorly into the intersphincteric space over the top of the puborectalis muscle, then descends through the iliococcygeus muscle into the ischiorectal fossa and perianal skin.
Extrasphincteric: The track Passes from the perineal skin through the ischiorectal fossa and levator muscles into the rectum. It lies entirely outside the external sphincter complex.

Fistula Treatments

Submucosal Superficial Fistulas (with or without abscess):

  • Fistulotomy: An incision along the fistula's length to open, drain, and heal. A small portion of the anal sphincter muscle might need to be cut to access the fistula. The goal is to heal without damaging the sphincter muscles, which could lead to complications like bowel incontinence.

  • Other Surgical Techniques: Seton placement, LIFT (ligation of intersphincteric fistula tract), or advancement flap procedures may be considered. Non-surgical treatments like fibrin glue injections are also an option, but generally less effective than surgical methods.

Intersphincteric, Transsphincteric, Suprasphincteric Fistulas:

  • Fistulotomy: An incision along the entire length of the fistula to open, drain, and heal, often used for simple fistulas.

  • Seton Placement: A rubber band or thread placed through the fistula tract to keep it open and allow it to drain. Helps prevent abscess formation and allows the fistula to heal from the inside out.

  • LIFT (Ligation of Intersphincteric Fistula Tract): An incision at the intersphincteric groove, identifying the fistula tract, ligating it close to the internal opening, removing the infected tissue, and suturing the area.

  • Endorectal Advancement Flap: Creating a flap from the rectal wall to cover the internal opening of the fistula after removing the infected tissue, reducing the amount of sphincter muscle cut.

  • Fibrin Glue or Collagen Plug: Non-surgical treatments involving injecting fibrin glue or inserting a collagen plug into the fistula tract to promote healing. Generally less effective than surgical methods.

Extrasphincteric Fistulas (most uncommon type):

  • Seton Placement: A rubber band or thread placed through the fistula tract to keep it open and allow it to drain. Used as a long-term solution or a preliminary step before more definitive surgery.

  • LIFT (Ligation of Intersphincteric Fistula Tract): Incision at the intersphincteric groove, identifying the fistula tract, ligating it close to the internal opening, removing the infected tissue, and suturing the area. Particularly useful for complex fistulas like extrasphincteric ones.

  • Endorectal Advancement Flap: Creating a flap from the rectal wall to cover the internal opening of the fistula after removing the infected tissue, reducing the amount of sphincter muscle cut, preserving continence.

  • Proctectomy: In severe cases, removal of the rectum may be considered, especially if other treatments have failed and the fistula is causing significant complications.

The choice of treatment depends on the complexity and location of the fistula, as well as the patient's overall health. Consulting with a colorectal surgeon is important to determine the best approach.

 

For the treatment of perianal fistulizing Crohn's disease, both antibiotics and biologics are commonly used. Here's an overview of each:

Antibiotics

Antibiotics are often used to manage infections and reduce inflammation associated with perianal fistulas. Common antibiotics include:

  • Metronidazole: Effective in reducing inflammation and infection.

  • Ciprofloxacin: Often used in combination with metronidazole for better results.

Biologics

Biologic agents target specific components of the immune system to reduce inflammation and promote healing. Common biologics include:

  • Anti-TNFα Agents: Such as infliximab (Remicade) and adalimumab (Humira), which are effective in inducing and maintaining remission.

  • Vedolizumab (Entyvio): A gut-specific integrin antagonist that helps reduce inflammation and maintain remission.

  • Ustekinumab (Stelara): Targets interleukin-12 and interleukin-23 to reduce inflammation and maintain remission.

Combination Therapy

In some cases, a combination of antibiotics and biologics may be used to achieve better results. It's important to work closely with your healthcare provider to determine the best treatment plan for your specific condition.

For more detailed information, you can refer to the American Gastroenterological Association's guidelines and the Toronto Consensus.

If you have any more questions or need further information, feel free to ask!

1. VESICOUTERINE FISTULA, is an abnormal connection between the bladder and the uterus. 

2. VESIVOVAGINAL FISTULA is an abnormal opening that forms between the bladder and the wall of the vagina.

3. Urethrovaginal – opening between the vagina and urethra, a part of the bladder

4.Rectovaginal – opening between the vagina and rectum/lower part of the large intestine, which carries stool out of the body

Not shown on this chart but fistula's that are common in Fistulzing Crohn's Disease.

  • Urethrovaginal – opening between the vagina and urethra, a part of the bladder
  • Enterovaginal – opening between the vagina and small intestine
  • Colovaginal – opening between the vagina and colon

 

The anal canal is the final portion of the gastrointestinal tract. It has a vital role in defecation and maintaining bowel control.  It is located within the anal triangle of the perineum between the right and left ischioanal fossae, and is  surrounded by internal and external anal sphincters, which play a crucial role in the maintenance of bowel control:

The mucosa in the anal canal is organized into longitudinal folds known as anal columns. These are joined at their inferior ends by anal valves. Above the anal valves are small pouches which are referred to as anal sinuses – these contain glands that secrete mucus.

The anal valves collectively form an irregular circle – known as a dentate line. This line divides the anal canal into upper and lower parts, which differ in both structure and neurovascular

Finding a painful lump near your anus can be scary and embarrassing. It’s hard to see the area yourself, even with photos, but it can be done. I've humorously crowned myself the "Perianal Selfie Queen," but feel free to send photos and knock me off my throne! I encourage all pictures, comments, questions, and suggestions.

Seek treatment promptly, as delaying care increases the chances of developing a fistula, even if you don't have fistulizing Crohn's disease. Based on my experiences, I recommend calling hospitals to check if they have a 24-hour colorectal surgery service, even if it means driving to a larger city. Go straight to the ER for an evaluation—tests and scans can be done without delays, and you may receive antibiotics and a follow-up plan with a colorectal surgeon.

Being in the ER ensures quick assessment and information for your doctors, allowing them to have a plan ready for you.

SETON Placement and Care

When you have your first perianal abscess, it's common to wake up with a seton, even though studies suggest that placing them at the initial incision and drainage can cause more harm than good. Setons are rubber bands that loop through the fistula and are sutured closed. After the initial incision and drainage, the surgeon may decide to place a seton.

Options for corrective surgery can be considered after 6 months without any abscesses. Depending on the location of the fistula and how much sphincter muscle is involved, options include fistulotomy, lay open, LIFT, advancement flap, or FiLAC. Fecal incontinence is a risk if more sphincter muscle is involved.

Caring for your seton involves keeping the area exceptionally clean. A sitz bath is needed after bowel movements. A detachable showerhead can be helpful for rinsing off without sitting in the tub. Using antibacterial soap and unscented baby wipes can also help. Tuck a 4x4 non-woven gauze between your buttocks to prevent irritation and protect against drainage. Desitin cream and 5% anorectal cream can help with pain and irritation.

If you are on Medicaid, SSI, or Medicare, check with HMOs for coverage of gauze and creams. Buying gauze in bulk from Amazon can save money.

For those who have had several unsuccessful surgeries and are doing well on biologics, long-term setons can be a viable option. With proper care, you can do almost anything you want. The fistula tract matures, pain subsides, and drainage slows. It's often better to wait with the seton than rush into corrective surgery to ensure all infection and inflammation are gone for a higher chance of success.

It's important to quit smoking, eat an anti-inflammatory diet, get enough sleep, and take care of ourselves.

Be well, my friends. Any other suggestions? Let me know in the comment box below.

 

This is an Ischiorectal abscess I had, with cellulitis extending around it, visible by the bright red coloring. The abscess was about the size of a mini Nerf football.

Despite contacting my surgeon multiple times and going to the ER for CT scans, the abscess remained undetected because it was very deep. I was put on Azathioprine, despite my body's inability to process Thiopurines, leading to severe issues with my CBCs and an enlarged spleen. My doctors overlooked these complications and continued with surgeries.

It's important to note that CT scans are often ineffective in finding fistulas and tracking abscesses—MRIs are recommended instead. If you feel something is wrong and are not being heard, keep advocating for yourself until someone listens. Blood work can also come back normal even during severe infections, especially when on biologics or other immune suppression drugs.

Being your own advocate is crucial. The later stages of this abscess were too gruesome to post, but it got significantly worse.