TY - JOUR
AU - Schneider, Judy
AB - Background The significance of the presence of rectal strictures in Crohn's disease has not been well studied. The aim of this study was to examine patients diagnosed with Crohn's disease associated with rectal strictures and to describe co-existing manifestations of perianal disease (abscesses, fistulae, or skin tags) and strictures located elsewhere in the colon or small intestine. Methods A cohort of 70 Crohn's disease patients with rectal strictures were compared with controls without rectal strictures matched for age, gender, and duration of disease. Analysis was done to better elucidate the association of rectal strictures with location of disease and other perirectal complications. Results The average age of both groups of our Crohn's disease patients was 54 years and the average duration of disease since diagnosis was 315 months for the patients and 314 months for the controls. 54% of patients were women and 46% were men. 61.4% of the study population had Crohn's colitis, whereas the remaining 38.6% of patients had ileo-colonic involvement. In contrast, the majority of the control population had ileo-colonic involvement (74.3%). Perirectal fistulae were present in 61% of patients with rectal strictures versus 34.3% of controls (p value = 0.001). Perirectal abscesses were present in 50% of rectal stricture patients vs. 17.1% of controls (p value < 0.001). Anal skin tags were observed in 23% of study patients vs. 15.7% of controls (p value = 0.275). 37% of patients with rectal strictures also had strictures more proximal in the colon as compared to 54% of controls (p value = 0.07). Only 10% of the study population had small bowel strictures vs. 55.7% of the controls (p value < 0.001). Conclusions This observational study of Crohn's disease patients suggests that the majority of patients with rectal strictures have colonic involvement and increased perianal fistulae and abscesses. Only a minority of patients was observed to have ileal or ileo-colonic disease, perianal skin tags, or strictures elsewhere. A future study will examine whether the severity of stricturing disease can tell us anything about the disease distribution, prognosis, or response to treatment. Patients with rectal strictures and associated perirectal disease may represent a specific phenotypic presentation of Crohn's disease that warrants further study and correlation with serological markers so as to better aid this subgroup of patients. Crohn' disease, rectal strictures, perirectal complications Crohn's disease (CD) is a chronic, transmural inflammatory condition that may affect any segment of the gastrointestinal tract. Colonic involvement is common in about 70% of CD patients. Perianal disease (including fistulae, abscesses, or skin tags) has been reported in roughly one-third of all documented cases of CD.1,–4 Perianal disease precedes or presents simultaneously with the diagnosis of intestinal disease in 36%–81% of these patients.1 The transmural inflammation of CD often leads to abscesses and fibrosis, which in turn may lead to strictures. The presence of rectal strictures in this subgroup of patients has historically been a predictor of poor outcomes and greater difficulty in management.5,6 In 1 recent study of Crohn's patients requiring surgical intervention, patients with anorectal strictures in the setting of colonic CD had a 33-fold increased likelihood of requiring permanent fecal diversion.5 The diagnosis of anorectal strictures in CD may be delayed, as their presence can be quiescent for many years unless symptoms of perianal sepsis or fistulae develop.6,7 Some authors have included the presence of rectal strictures in classification systems designed to better delineate the nature of perianal CD.8,–11 But generally, the importance of rectal strictures and their association with other perianal findings have not been well reported. The aim of this study is to examine CD patients with rectal strictures and compare the nature of their disease to a group of matched (for age, sex, and disease duration) CD patients without rectal strictures in regard to perirectal fistulas, abscesses, anorectal skin tags, and strictures elsewhere in the bowel. Materials and Methods After obtaining Institutional Review Board approval, a cohort of 70 CD patients with rectal strictures was identified from the inflammatory bowel disease (IBD) database kept by the senior author and a thorough retrospective chart review was then undertaken. For the purposes of this study, rectal strictures were defined by the presence of luminal narrowing of the anorectal wall (regardless of overall severity) on digital rectal examination. The nature of disease with respect to patient gender, age, duration and location of disease, presence of perianal disease (fistulae, abscesses, and skin tags), and stricture location was noted. Information was collected for 70 CD patients without rectal strictures, derived from the same database, and matched for age, sex, and duration of disease to the study group. Statistical analysis was then performed to compare these variables in the 2 groups to determine if any statistically significant distinctions existed between them. Results The average age of both groups of our CD patients was 54 years (STD = 12.7 for the cases and 12.6 for the controls) and the average duration of disease since diagnosis was 315 months for the patients and 314 months for the controls (STD = 131.8 and 123.4, respectively). In all, 54% of patients were women and 46% were men (Table 1). 61.4% of the study population (patients with rectal strictures) had Crohn's colitis, whereas the remaining 38.6% of patients had ileo-colonic involvement. No patients had strictly ileal involvement (Fig. 1). In contrast, the majority of the control population (CD patients without rectal strictures) had ileo-colonic involvement (74.3%). Perirectal fistulae were present in 61% of patients with rectal strictures versus 34.3% of controls. Perirectal abscesses were present in 50% of rectal stricture patients versus 17.1% of controls. Anal skin tags were observed in 23% of study patients versus 15.7% of controls (P = 0.275) (Fig. 2). 37% of patients with rectal strictures also had strictures more proximal in the colon as compared to 54% of controls (P = 0.07). Only 10% of the study population had small bowel strictures versus 55.7% of the controls. Table 1. Matching of Study and Control Groups     View Large Table 1. Matching of Study and Control Groups     View Large Figure 1. View largeDownload slide Disease distribution. Figure 1. View largeDownload slide Disease distribution. Figure 2. View largeDownload slide Association of other perirectal complications and strictures more proximal in the bowel. Figure 2. View largeDownload slide Association of other perirectal complications and strictures more proximal in the bowel. Discussion Compared to CD patients without rectal strictures we found that patients with strictures discovered on digital rectal examination had significantly more isolated colonic disease. In turn, they were less likely to have diffuse ileo-colonic disease. The finding could not be used to make any inferences about the presence of strictures more proximal in the colon as there was no significant difference between the 2 groups (Fig. 2). Conversely, there were far fewer small bowel strictures associated with rectal stricture patients as compared to the control group. It is unclear at this time if this represents a different mechanism of stricture formation in the small bowel versus the colon or is simply a result of a selection bias as the total number of all strictures regardless of location was similar in the 2 patient groups. It has been postulated that inflammation and scarring secondary to the presence of perirectal and intrarectal fistulae and abscesses lead directly to the development of anorectal strictures. Indeed, more perirectal and intrarectal fistulae and abscesses were present in the rectal stricture population. Interestingly, there was an equal likelihood of having anal skin tags between the 2 groups. It is likely then that the pathophysiology of the anorectal skin tags is independent of the local processes leading to the abscesses, fistulae, and strictures and has been the subject of a separate investigation of the mechanism that leads to their appearance.12 To our knowledge, this study is the first trial reported specifically to seek associations of CD with rectal stricturing. As the search for the genetic factors that contribute to the development of CD proceeds it will become increasingly more important to define different phenotypic presentations of this illness. Improvements in technology will continue to aid in classifying and understanding perianal CD. In addition to physical examination and examination under anesthesia, newer modalities such as endoscopic ultrasound and MRI are becoming the standard of care in the evaluation of patients with perianal disease.1 Therapies will become more specialized and individually tailored to specific groups of patients, possibly based on genetic variables. In the future we will examine whether the severity of stricturing disease can tell us anything about disease distribution, prognosis, or response to treatment. We believe that patients with rectal strictures and associated perirectal disease may represent a specific phenotypic presentation of CD. This warrants further study and perhaps correlation with serological markers to better classify this subgroup of patients with severe outcomes.13 References 1. AGA medical position statement: perianal Crohn's disease. Gastroenterology.  2003; 125: 1503– 1507. CrossRef Search ADS PubMed  2. Schwartz DA, Pemberton JH, Sandborn WJ. Diagnosis and treatment of perianal fistulas in Crohn's disease. Ann Intern Med.  2001; 135: 906– 918. CrossRef Search ADS PubMed  3. Lapidus A, Bernell O, Hellers G, et al.   Clinical course of colorectal Crohn's disease: a 35-year follow-up study of 507 patients. Gastroenterology.  1998; 114: 1151– 1160. CrossRef Search ADS PubMed  4. Van Dongen LM, Lubbers EJ. Perianal fistulas in patients with Crohn's disease. Arch Surg.  1986; 121: 1187– 1190. CrossRef Search ADS PubMed  5. Galandiuk S, Kimberling J, Al-Mishlab T, et al.   Perianal Crohn's disease: predictors of need for permanent diversion. Ann Surg.  2005; 241: 796– 801. CrossRef Search ADS PubMed  6. Linares L, Moreira LF, Andrews H, et al.   Natural history and treatment of anorectal strictures complicating Crohn's disease. Br J Surg.  1988; 75: 653– 655. CrossRef Search ADS PubMed  7. Greenstein AJ, Sachar DB, Kark AE. Stricture of the anorectum in Crohn's disease involving the colon. Ann Surg.  1975; 181: 207– 212. CrossRef Search ADS PubMed  8. Fielding JF. Perianal lesions in Crohn's disease. J R Coll Surg Edinb.  1972; 17: 32– 37. PubMed  9. Hughes LE. Clinical classification of perianal Crohn's disease. Dis Colon Rectum. . 1992; 35: 928– 932. CrossRef Search ADS PubMed  10. Hughes LE. Surgical pathology and management of anorectal Crohn's disease. J R Soc Med.  1978; 71: 644– 651. CrossRef Search ADS PubMed  11. Pikarsky AJ, Gervaz P, Wexner SD. Perianal Crohn's disease: a new scoring system to evaluate and predict outcome of surgical intervention. Arch Surg.  2002; 137: 774– 777. CrossRef Search ADS PubMed  12. Bonheur JL, Korelitz BI, Braunstein J, et al.   Perianal skin tags in inflammatory bowel disease. Am J Gastroenterol.  2006; 101(Suppl): A316. 13. Targan SR, Landers CJ, Yang H, et al.   Antibodies to CBir1 flagellin define a unique response that is associated independently with complicated Crohn's disease. Gastroenterology.  2005; 128: 2020– 2028. 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TI - Rectal strictures in Crohn's disease and coexisting perirectal complications
JF - Inflammatory Bowel Diseases
DO - 10.1002/ibd.20264
DA - 2008-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/rectal-strictures-in-crohn-s-disease-and-coexisting-perirectal-kqNpowYLjY
SP - 29
EP - 31
VL - 14
IS - 1
DP - DeepDyve
ER -