Introduction

Fistulizing perianal Crohn’s disease (CD) is a disabling condition affecting up to 30 % of patients. While mucosal healing is associated with a better clinical outcome in luminal CD, the objective of the management of perianal CD is less clear. Radiological parameters are rarely considered as an outcome in perianal CD. Some studies have suggested that a high degree of fibrosis of the fistula tract was associated with a better clinical outcome. The aim of this study was to describe the natural history of perianal CD including MRI parameters and to identify clinical and radiological factors of perianal CD relapse and radiological healing.

Aims & Methods

All pelvic MRI performed for fistulizing perianal CD in the CHU of Liège, Belgium, between 2018 and 2023 were collected. MRI examinations were performed according to the protocol of the institution, using a 1.5-T [Siemens Aera ou Sola] or 3-T [Siemens Vida] machine, including T2 turbospin- echo, T2 TSE fat-saturated, T1 TSE FS before contrast in the axial plane and T1 TSE FS after gadolinium. The MAGNIFI-CD index and the Van Assche index were evaluated for each patient. The degree of fibrosis of the fistula tract was evaluated by two radiologists, blinded for the clinical history. The first MRI was evaluated in all patients. Patients with perianal flare had only one MRI included in the analysis. The first and the last MRI performed during the study period were analyzed, if available, in patients without perianal flare. Parianal flare was defined by the drainage of an abscess or a stoma for active perianal CD. Radiological remission was defined by a fibrosis of the fistula tract of ³80% or a MAGNIFI CD score of 0.

Results

Seventy-five pelvic MRI from 60 patients were included in the study. The median age of the patients was 37.0 (30.0 - 48.5) years old, 37 (62%) patients were male, the median duration of perianal CD was 36.00 (0.60 - 123.00) months, 19 (31.7%) had a seton at the time of the first MRI, 23 patients (40%) were on anti-TNF. Nineteen (32%) patients, required abscess drainage in the follow-up period. Sixty-three % were on anti-TNF at the time of the drainage. No clinical nor radiological factors at baseline were predictive of perianal flare.
Fifteen patients without perianal flare had a second MRI during the follow-up. Seven patients (46,7%) had radiological healing at the end of the follow-up. One patient (6.7%) had radiological healing at the first MRI but not at the last MRI, 2 patients (13,3%) had radiological healing at both MRI 1 and 2 (13.3%), 5 patients (33,3%) had no radiological healing at MRI 1 but had radiological healing at MRI 2. Longer duration of perianal CD was associated with higher rates of radiological healing at the last MRI whereas high VA hyperintensity T2 (OR=0.13, p=0.099) and hyperintensity on postcontrast T1 (OR=0.11p=0.071) at the first MRI were predictive of absence of mucosal healing during the follow-up.

Conclusion

One third of the patients with perianal CD required abscess drainage whereas about half of the patient had radiological healing at the end of the follow-up. No clinical predictive factors were associated with perianal flare and few radiological factors were predictive of radiological healing. Predicting the outcome of perianal disease remains challenging in clinical practice. Radiological factors are promising and should be validated in a prospective cohort.

Disclosure

Speaking fees, consulting fees, travel fees, grant from: Abbvie, Alfa Sigma, Takeda, Janssen, BMS, Pfizer, Lilly, Roche, Fresenius Kabi, Biogen, celltrion, ferring

Introduction

Perianal fistula is the most common complication of Crohn’s disease (CD), affectingapproximately 40% of patients. For patients with perianal abscesses and active draining fistula, seton or fistulotomy should be performed, followed by aggressive medical therapies, including anti-TNF agents. However, a significant proportion of patients are non-responders. There is insufficient evidence to confirm the efficacy of ustekinumab (UST), in promoting fistula closure in perianal fistulizing Crohn’s disease (CD) patients.

Aims & Methods

We aimed to evaluate the efficacy of UST in a real-world setting.
The data were retrospectively analyzed. Clinical and endoscopic changes were evaluated. Fistula radiological outcomes were determined using MRI.

Results

A total of 72 patients diagnosed with CD and receiving scheduled UST treatment were enrolled. Of these, 45 patients were excluded due to the absence of perianal fistula based on clinical symptoms and MRI scans, 5 for insufficient follow-up duration, and 5 for incomplete data. A total of 17 eligible patients were finally included, 2 patients did not have follow-up MRI, 65% (n=11) of whom were male, with a mean age of 28.2 ± 2.0 years at diagnosis and a mean disease duration of 3.4 ± 0.6 years. As for the Montreal classification, 62% of the patients were assigned to B1 (non-stricturing, non-penetrating) and 70% to L3 (ileocolonic) phenotypes. Most fistulas were inter-sphincteric (65%). After 58,66+-13,48 weeks of UST therapy, fistula closure was shown in 40% (n=6) of patients. In patients with endoscopical remission at 6 months of UST therapy, we did not detect significant difference in fistula closure (57.1% vs 42.9%, p=0.315).

Conclusion

UST is effective in promoting clinical and radiological fistula remission in patients with CD. Intestinal endoscopical remission may not be correlated with fistula outcome. Further research is needed for determining ustekinumab therapy efficacy for perianal fistula.

Introduction

In complex perianal fistulizing Crohn’s disease (PFCD), rectal involvement is associated with worse outcomes, likely due to persistent inflammation at fistula internal openings. It is linked to lower remission rates and higher failure rates after anti-TNF-alpha induction, and current guidelines consider it a contraindication to surgical repair. However, its predictive value for secondary loss of response (LOR) to anti-TNF-alpha therapy remains unclear. While endoscopy and MRI can assess rectal disease, the former is limited to mucosal findings, whereas MRI provides comprehensive evaluation of transmural and pelvic inflammation.

Aims & Methods

This study aimed to assess the predictive value of rectal involvement for secondary LOR using both modalities. We conducted a longitudinal study (2000–2023) at a tertiary inflammatory bowel disease center. Included were PFCD patients naïve to anti-TNF-alpha therapy who achieved response or remission after induction. Patients with inadequate follow-up or poor adherence were excluded. Rectal involvement was defined as wall thickening >3 mm on MRI, and mucosal inflammation, a single ulcer >5 mm, or ≥3 ulcers <5 mm on endoscopy. Patients were stratified by MRI findings. Logistic regression identified predictors of secondary LOR, and Kaplan–Meier analysis assessed recurrence-free survival (RFS).

Results

A total of 80 patients were included (male-to-female ratio: 1.33). MRI-detected rectal wall thickening was present in 49 patients (61.3%). The two groups were comparable in baseline demographics and disease phenotype. Mean age at Crohn’s disease diagnosis was 28.9 years in the thickening group and 27.4 years in the non-thickening group; mean age at PFCD onset was 32.5 and 31.5 years, respectively. Most patients were treated with infliximab (88%), and the remainder received adalimumab (12%). Endoscopic rectal involvement was documented in 37 patients (46.3%). Secondary LOR occurred in 64.3% of patients overall, with a mean time to LOR of 17.8 months. Notably, MRI-defined rectal thickening was independently associated with increased odds of LOR (OR = 6.35, p = 0.002), whereas endoscopic assessment did not show a significant association. Patients without MRI-defined thickening had significantly higher RFS at 12, 36, and 60 months (86%, 72%, 57%) compared to those with rectal thickening (57%, 35%, 28%; p < 0.001).

Conclusion

Baseline MRI-detected rectal thickening is a strong, independent predictor of secondary LOR and reduced RFS in PFCD. MRI should be integrated into early disease assessment to identify high-risk patients who may benefit from intensified therapy and close monitoring. Resolution of rectal inflammation may restore eligibility for surgical repair. Further prospective studies comparing MRI and endoscopic markers are warranted to guide tailored treatment strategies.

Introduction

Crohn's disease (CD) is associated with a high risk of complications, stenosis and fistula frequently requiring surgery.
The aim of our work is to study the epidemiological profile of patients operated on for CD, to compare operated and non-operated patient and to determine the predictive factors for recourse to surgery.

Aims & Methods

This is a retrospective descriptive, comparative and analytical monocentric study over 40 years from January 1983 to april 2023 in a gastroenterology department including all patients followed for CD and operated on. Data was collected from patient registers.
We compared the operated and non-operated group, then we studied the factors associated with surgery in univariate and then multivariate analysis.

Results

Of 1103 patients followed for CD, 31.82%(351) were operated, including 86%(302) operated once, 12%(43) operated twice and 1.4%(5) operated 3 times. The median age of diagnosis was 31[22.5-40]years and the sex-ratio F/M=1.1.
A history of appendectomy was found in 17.2%(60) of patients. Smoking is found in 26.9%(94) of patients.
Patients operated on have an ileocolic location in 68.5%(237), colonic in 14.7%(52), ileal in 12.7%(44) of cases, and upper location in 3.8%(13).
The stenosing phenotype is observed in 38.4%(131) of patients, fistulizing in 35.2%(120) and inflammatory in 26.4%(90). Anoperineal manifestations were associated in 38.8%(122).
Recourse to corticosteroid is observed in 44.2%(155) of operated patients, 40.5%(142) who received immunosuppressive treatment and 26.6%(93) who had benefited from biotherapy.
19.9% (70%) were operated on following a complication of their disease, including 11.4%(8) of those operated on for severe acute colitis, 51.4%(36) for an occlusion, 22.8%(16) for an intestinal perforation, 17.1% (12) for a deep abscess and 4.2% (3) following degeneration.
By comparing the group of operated and non-operated patients, the diagnosis age <40 years was found at a higher rate in the operated p <0.001. In these patients, there is a higher frequency of ileocolic localization, fistulizing and stenosing forms and associated MAP (p<0.001/0.009). We noted a higher rate of patients who were under immunosuppressant p<0.001 and under biotherapy p=0.03 in operated patients.
In multivariate analysis, a history of appendectomy is associated with a high risk of surgery (OR=1.8, 95%CI:0.06-1.2, p=0.02) as well as the fistulizing phenotype (OR=6.5, 95%CI:1.4-2.3 , P<0.001) and the stenosing phenotype (OR=5.3, 95% CI:1.2-2, P<0.001). The occurrence of a complication (OR=9, IC95%=1.5-2.8, p<0.001) as well as the use of immunosuppressants (OR=1.6, IC95%: 0.1-0.8, p=0.001) are associated with a risk surgery high.
The use of corticosteroid therapy is associated with a lower risk of surgery (OR=0.6, 95%CI: -0.8;-0.1, p=0.006).
Other factors such as sex, smoking, location, anoperineal manifestations and biotherapy are not factors associated with surgery.

Conclusion

Despite the revolution in medical treatment, surgery remains a fundamental treatment in the management of CD. In our series, the history of appendectomy, the fistulizing and stenosing character of the disease, the treatment with immunosuppressant and the occurrence of complications are associated with an increased risk of recourse to surgery.
Corticosteroid therapy is associated with a low risk of surgery.
Sex, smoking, location and anoperineal manifestations are not associated with the risk of surgery.