Perianal fistulas in patients with inflammatory bowel disease

Fistula in ano represents a challenging pathology for both the patient and the clinician, and management can be made even more difficult in the setting of Crohn's disease. Up to 54% of patients with Crohn's disease will suffer from anorectal involvement that can have a profound impact on quality of life. However, treatment of Crohn's-related fistulas can be fraught with complications, including delayed wound healing, persistent fistula, and fecal incontinence. As such, a thoughtful, moderated, and well-informed approach is necessary when evaluating and treating a Crohn's-related anal fistula. In this article, we review the current literature regarding diagnosis and treatment of anal fistulas in this specific patient population. The tenets of management include control of the underlying sepsis and proctitis, accurate diagnosis with exam under anesthesia, appropriate imaging, with either magnetic resonance imaging or endoanal ultrasound, and, finally, the implementation of appropriate medical and surgical therapies. Further, we define which patients can avoid morbidity associated with aggressive therapy and review the current management of Crohn's-related rectovaginal fistulas and fistulas following proctocolectomy and ileal pouch-anal anastomosis.