#22-23 Importance of Perineal Disease in Crohn's

Study #22 and #23

This is one of the most important and most ignored papers in the CV, identifying a subgroup of patients with Crohn’s disease who have metastatic Crohn’s in the perineum. This leads to poor wound healing, terrible results from surgery, and permanent stomas. The arrival of anti-TNF biologics changed the game and allows surgery and healing. The diagnosis of perineal Crohn’s is clinical and histologic (granulomas in the perineal skin) and is an important one to make. Study 23 is not really a study but my response to Study 22 being ignored.

Study 22

Figg RE. Church JM. Perineal Crohn's disease: an indicator of poor prognosis and potential proctectomy. Diseases of the Colon & Rectum. 2009; 52: 646-50.

Purpose: There is a subset of patients with perianal Crohn's disease whose course is unusually severe. The hypotheses of this study are that these patients often have direct perineal involvement with Crohn's disease and that this involvement can be recognized clinically.

Methods: A prospective database with data from 1989 to 2005 was examined for patients with perianal Crohn's disease. Patients were divided into those with and those without perineal involvement, defined by the presence of at least one of the following findings: spontaneous perineal ulceration; nonhealing, painless fissures; or waxy perineal edema. Presentation, treatment, and outcome of the two groups were compared.

Results: Seventy-two patients were identified, 19 with perineal involvement and 63 without. Perineal Crohn's disease was more often seen in women, presented at a younger age, and was associated with less small bowel and more colonic Crohn's. The chances of healing in patients with perineal Crohn's disease were lower (32 vs. 66 percent) and proctectomy was more likely (26 vs. 3.7 percent) than when the perineum was normal.

Conclusion: Perineal involvement with Crohn's disease can be diagnosed on physical examination and confirmed by the finding of granulomas. When perineal involvement is suspected, surgery should be avoided and consideration given to medical therapy.

Study 23

Church J. Missing the Boat? Appreciating the Importance of the Pathophysiology of Perianal Crohn's Disease in Guiding Biological and Surgical Therapy. Dis Colon Rectum. 2018; 61: 529-531.