FISTULAS AND ABSCESSES IN SYMPTOMATIC PERIANAL CROHNS-DISEASE

Perianal disease occurs in up to 90% of patients with Crohn's disease [1-4]. Many of these patients have only mild symptoms or are asymptoma tic and thus require no intervention. Clinical features are variable a nd include hypertrophic skin tags, ulceration, perianal abscess and fi stulae, anal canal ulcers, fissures, induration and stenosis. Perianal abscess and fistula often occur simultaneously and are usually sympto matic. Symptoms range from pain, discharge, bleeding, to gross faecal incontinence with restriction of lifestyle and sexual activity. There is little uniformity amongst clinicians in the investigation and manag ement of perianal Crohn's disease [5]. This is due, in part, to the va riability in both frequency and severity of attacks and to spontaneous remissions and exacerbations of perianal disease. Secondly, assessmen t of severity of illness and the response to treatment is difficult to objectively quantitative. Improvement in quality of life is the aim o f therapy not cure of perianal disease. Investigative modalites for pe rianal Crohn's are changing due to the limitations of conventional fis tulography, CT scanning and clinical evaluation. MRI scanning has been introduced more recently, however, requires an endorectal coil to obt ain good anatomical visualisation and has limited availability [6-12]. Endorectal ultrasonography has been shown to detect more abscesses an d fistula in Crohn's patients than clinical examination, proctosigmoid oscopy and CT scanning, better delineation of fistulous tracts than fi stulography and has the ability to change the clinical management of r eferring physicians [13-16]. Most fistulae are not explored surgically and therefore the documentation of fistulae in symptomatic Crohn's di sease has been limited and are usually classified only as high or low [4]. Park's has pointed out this terminology for cryptoglandular disea se is i'... an ambiguous one'' and hence developed a more precise nome nclature [17]. The objective of this study was to document prospective ly by transanorectal ultrasonography fistulae and abscesses in symptom atic perianal Crohn's disease and to classify them according to Park's nomenclature and determine the incidence of these at the time of refe rral for a new exacerbation of the disease. Anal wall thickness was me asured prospectively by ultrasonography as it has been shown to be inc reased in patients with perianal Crohn's disease and may reflect disea se activity [13, 18].