ANAL LESIONS - ANY SIGNIFICANT PROGNOSIS IN CROHNS-DISEASE

Aim: Work-up of anoperineal lesions usually includes indices of clinic al activity as well as diagnostic criteria of Crohn's disease but thei r prognostic implication remains unclear. This prospective study was c onducted in order to evaluate the overall incidence of anoperineal les ions and their relation to the natural history of underlying intestina l Crohn's disease with special reference to the steroid-dependent stat e of the patients. Patients and methods: One hundred and one patients (46 males, 55 females, aged 34 +/-14 years; range: 15-79) were consecu tively referred to our institution (May 1991 to May 1994) for intestin al symptoms related to Crohn's disease (mean duration 66+/-66 months). They all underwent a proctological examination regardless of perineal symptoms. The Cardiff classification was used to describe anoperineal lesions. Patients with anal lesions (64) differed from those without (37): male predisposition (53% vs. 32%, P<0.05), more frequent rectal involvement (75% vs. 24%, P<0.001) and more acute lesions observed at proctoscopic examination (42% vs. 16%, P<0.05). Age of onset, surgical past history of Crohn's disease, colonic or ileal involvement, or Har vey-Bradshaw score were not different between groups. Results: Patient s with anal ulceration (43) as compared to patients having anal involv ement without ulceration experienced pain more frequently (constant pa in: 56 vs. 14%; defecatory pain: 35 vs. 19%) and a more severe evoluti on of intestinal (40 vs. 22%, P<0.05) and anal (42 vs. 12%, P<0.05) in volvement. In those with an aggressive ulceration (U2, 28 patients), d aily stool frequency (5.1+/-3 vs. 3.6+/-2.5, P<0.05) and clinical scor e (9 +/- 5 vs. 7 +/- 3) were more pronounced. Steroid therapy dependen cy occurred more frequently in the group with anal ulceration (35 vs. 16% and 40 vs. 17%, respectively, P<0.05). Similar associations were o bserved for cases of anal involvement (34 vs. 5%, P<0.01) and azathiop rine was more frequently required (39 vs. 5%, P<0.01) than in those fr ee of anal lesions. During follow-up, eight other patients required az athioprine (steroid dependence in six) and seven of them had anal lesi ons at referral. At the endpoint of the study, one out of two patients with anal lesions required azathioprine most often due to steroid dep endency of the intestinal involvement (30/64 vs. 4/37, P<0.005). Concl usion: Anal ulcerations are a reliable severity index of Crohn's disea se in both short- and long-term prognosis but their link to the steroi d status of the intestinal disease remains unclear.