Perianal Crohn’s Disease with Dr. Luca Stocchi

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Welcome to another episode of Butts & Guts, I'm your host Scott Steele, Chairman of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. I'm very pleased to have Dr. Luca Stocchi here with us. Luca is the head of research in the Department of Colorectal Surgery and is also a full professor of surgery at Cleveland Clinic Lerner College of Medicine. And today we're going to talk a little bit about perianal Crohn's disease. Luca, welcome to Butts & Guts.

Luca Stocchi: Thank you for having me.

Scott Steele: I want to start out by having you tell the audience a little bit about you. How did it wind up that you were born in Italy and wound up here at Cleveland Clinic?

Luca Stocchi: I was born in Italy and I went to medical school there, and then I came to the United States with the idea of spending a period, which became basically the rest of my life. So I did residency in the United States and here I am.

Scott Steele: Luca, let's take a step back before we hone in on perianal Crohn's disease and just talk about Crohn's disease in general. What is Crohn's disease?

Luca Stocchi: It is a chronic inflammatory disease that can involve the entire gastrointestinal tract and, therefore, it's so far a disease that has not been able to be completely cured by either medical or surgical means. Fortunately, it's a variable disease and some individuals have a very favorable course. Unfortunately, some other individuals have a very unfavorable course that requires multiple operations, interventions and prolonged medical management. It's a very bizarre disease that can vary from mild to extremely aggressive and is associated with poor quality of life.

Scott Steele: What is perianal disease? Apart from Crohn’s, what type of disease processes fit into perianal disease?

Luca Stocchi: A variety of conditions ranging from lumps and bumps around the anus to small holes inside of the anal canal, to a collection of pus referred to as abscesses, which can cause acute symptoms of infection. It can cause pain, fevers and discomfort, as well as malodorous discharge. And all of this can also be associated with improper upper bowel movements and bowel function, which can lead at times to the incontinence of stools.

Scott Steele: What makes perianal Crohn’s disease different from run-of-the-mill disease processes like you were talking about before? So somebody could see a hemorrhoid or a fissure or a fistula or tags or anything in the in the anal region. What is it about Crohn’s that makes those a little bit different?

Luca Stocchi: The difference is that it is a manifestation of a chronic condition that can be associated with either location of disease and is recurrent, and therefore difficult to eradicate. In this specific case, a mild form of perianal Crohn's disease may at times behave similarly to the more sort of garden variety perianal Crohn's disease. So there may be situations where the treatment is not so different, but I think that the context is profoundly different, and that is where we as caregivers need to be attentive to the context of perianal Crohn's disease.

Scott Steele: What percentage of patients that have Crohn's disease will suffer from perianal Crohn's disease? And is it a different patient population? Is it a good prognosis or a bad prognosis?

Luca Stocchi: I think I would say about 30 percent of patients to 35 percent of patients have some manifestation, and it depends on the definition of perianal Crohn's disease in the various studies. In general it is associated more commonly with Crohn's disease located in the large intestine and is an adverse prognosticator. So if there's also concomitant bowel disease, the presence of perianal Crohn's disease generally indicates a greater aggressiveness of the disease as a whole. There may be other cases where perianal Crohn’s diseases is the initial presentation of disease, and the disease itself is not diagnosed, and it may take even years to diagnose the disease. And the manifestation can be relatively mild.

Scott Steele: Luca, you brought up a great point there, and one I want to make sure the audience understands. You said that there are patients that the perianal disease may present as their first initial symptom or, or presentation of Crohn’s. So what are some of the symptoms of perianal Crohn's disease? And if at all are there symptoms, again different from the normal perianal disease and that of Crohn’s?

Luca Stocchi: The symptoms can be similar to the general symptoms that we mentioned earlier. So a sense of pain, heaviness, discharge, unusual discharge, purulent discharge. Sometimes I’ll see it with fever with alteration of bowel function. And the idea that this could be related to Crohn's disease may take some time to be understood. But I think that there are some signs that could make it more suspicious.

For example, the young age of the patients there is general, so again it's possible to have garden variety, or as we say as doctors idiopathic pain, or Crohn's disease. I think a young patient raises the suspicion, and then when we see such a patient we need to elicit the history and see if they have a history of inflammatory bowel disease, which would be unfortunately a red flag. And then I think that as caregivers we can see particular features of the manifestations of disease, which probably the patient himself or herself cannot distinguish, but we can and, for example, the course of some of these tunnels that are called fistulas that can develop.

The fact that these tunnels can have branching patterns instead of having just a single tunnel. And then other manifestations within the anal canal, such as fissures or the particular skin tag that a patient can develop in these circumstances, which have a particular form and are sometimes particularly large so that they have been called cauliflower skin tags. When you see any of these manifestations the level of suspicion increases. But again, even though there are a number of features in the individual patients, it may be impossible even for years to characterize this as for sure as a type of fissure associated with Crohn's disease.

Scott Steele: Let's take a scenario now: I'm a patient doing well, otherwise young and healthy. I felt something on my bottom and I went to see my primary care doctor, and they said indeed I have a fistula or a tag or a fissure. But they said to me that “I'm concerned that this might be Crohn's disease and I'd like you to see a colorectal surgeon.” Walk me through what that patient can expect during an office visit with you.

Luca Stocchi: A conversation on family history, a conversation on other symptoms – particularly bowel symptoms, abdominal pain, diarrhea, inability to tolerate food, episodes of vomiting, abdominal distension, any admission to the hospital, what was the reason if there was a reason associated with that. If they ever had imaging to their abdomen, that could elicit possible bowel disease. And then more specific to the issue of perianal disease: How long has this been going on? What are the characteristics? Is it a more chronic or intermittent process, or is it an acute process in the face of otherwise excellent health.

And then I, I would try to do, if the patient can tolerate that, an examination of the anus including anoscopy, assessing the anal canal and seeing the characteristics of the disease. As we said, the possibility of fissure, the possibility of stricture, the possibility of inflammation in the anal canal, the possibility of multiple fistulas, abscesses and then skin tags. Also, the position of the fissure, so if it's not the more idiopathic garden variety, this kind of fissure is located posteriorly. A location that is off that position is generally a reason for suspicion that it's associated with Crohn's disease. With the skin tag, there are characteristics, as we said, and then I would probably order down the line an endoscopy, and a colonoscopy which can give us an idea of the condition of the rest of the lining of the large intestine. And if I have a suspicion for symptoms in the abdomen, a CT enterography too specifically look at the small bowel.

Scott Steele: That's a lot to unpack there. So just kind of working through that sounds like they're going to come in and get a nice discussion about the different things, give an examination of that perianal region, and then potentially a smaller scope that looks at the inside of the anus. You also mentioned that we want to evaluate the whole bowel. So we want to get a special CT scan to take a look at the small bowel and then the colonoscopy for that evaluation of the colon. Medical treatments for perianal Crohn’s, what are the medical treatments for perianal Crohn’s and does it depend on the type of lesion that you're dealing with down there to determine what is a better response to medical therapy versus what may need to go on to surgery?

Luca Stocchi: I think the medical options are generally viewed in the modern management of perianal Crohn's disease as complimentary to surgery. It's important first too be in agreement with diagnosis, because some of the medications have significant adverse effects, and our gastroenterology colleagues do not want to use medications half-heartedly if the diagnosis is not clear. But once the diagnosis is clear, I think that there are a number of options that are available.

The first and most important thing is we need to be sure that there is no active and undrained pus in the area. That is the first and foremost goal that we need to achieve. Once this is cleared then all the options are open. Options range from antibiotics, which can be used in the short term sometimes to help with the operation. If there are manifestations, such as cellulitis, in some cases patients that are immunosuppressed, that local procedure can drain pus. Medical options can include immunosuppressants, which are particularly useful in case of synchronous bowel disease and are accepted, validated long-term options.

And then there is a class of biologics, which is a class that probably has the greatest effectiveness within the medical options in the management of perianal Crohn's disease. That has a variety of four or five agents that are commonly used now and can be used optimally to address synchronous Crohn's disease in the bowel. But it can be also effective when the disease is limited to perianal Crohn's disease. I want to emphasize the modern management of Crohn's disease is generally accepted and, and numerous studies have proven this, that it's a combination of medical management and surgical management. I think it's unusual for perianal Crohn’s disease, at least in the modern management, to be managed medically. We resort to surgery only once medical management fails, which is somewhat a difference when compared to bowel Crohn's disease.

Scott Steele: We're going to have it as a given that the patients are optimally medically managed but they come and see you. And because there are a large number of different pathologies within the perianal Crohn’s disease, I'm just going to kind of walk through so the patients can get a rough idea. But just in very broad general terms, understanding that individual results may change abscess, how is that treated?

Luca Stocchi: The optimal treatment is incision and drainage. If a patient is very motivated and tolerates pain well, this could be done in the office under local anesthesia. I think most patients with perianal Crohn's disease, having an abscess requires treatment under anesthesia, usually an outpatient procedure. And at that time the abscess is drained, we look at possibility of synchronous fistulas, which can be present or not and which can be identified or not. If there is no fistula identified, the treatment is limited to incision and drainage of the abscess.

Scott Steele: Okay let's jump right into fistula, which you mentioned earlier in the podcast, that was a tunnel from the inner part of the lining of the anal canal itself to the outer part of the skin. How are those, in general, treated?

Luca Stocchi: In general they're treated with the placement of a sort of a loose rubber band, which we call Seton, which has the purpose of controlling the discharge and controlling the most difficult symptoms associated with this condition. This is a solution that can be associated with the long-term permanence of drainage in the fistula, and down the line more aggressive options can be used to address the fistula and try to close it for good. But I think in the initial assessment of a fistula, an initial treatment in most patients with Crohn's disease would be placement of a loose seton.

Scott Steele: If you're speaking to surgeons out there who don't see a lot of Crohn’s, do you have a word of advice, or maybe a word of caution, when dealing with fistulas in the Crohn's patient right off the bat?

Luca Stocchi: I would be very careful to do a fistulotomy on them. To fillet open the fistula, it's an option, it's possible, but I think that especially in the acute setting it’s important to assess what else is going on in terms of intestinal disease. The priority is controlling symptoms. I think that the loose Seton allows for temporizing future possible management with other options, and effectively controlling Setons without cutting any bridges. It is still possible down the line to do a fistulotomy in those selected cases where a fistulotomy is appropriate and successful.

Scott Steele: Anal fissure.

Luca Stocchi: Anal fissure is a variable manifestation of symptoms of Crohn's disease. I think that as far as surgical management, there are not a lot of good options. I think it's important to understand if an anal fissure is part of the complex presentational period of Crohn's disease, it’s not responsible for symptoms. If it is uh associated with pain, which is not very common. Most of the fissures are not associated with intrinsic pain. I think that is one of those situations where medical management is generally more effective than surgery. I think that unlike in the idiopathic fissure, Crohn's fissures should not be aggressively treated with surgery, particularly surgery that involves cutting out the sphincter muscle. And there can be a role in injecting steroids locally under anesthesia, but this can be sometimes only associated with temporary improvement and is not a long-term solution. I think that the most successful patients who have fissures and have symptoms are those who respond to medical management. There are not a lot of surgical procedures that we can do to correct that specifically and when considered alone.

Scott Steele: So you also mentioned how those patients present. You brought up the term of the larger skin tags, sometimes referred to as a lot of different things. But it's even been referred to as the elephant ear because they're bigger and they're flatter. So what do you do about those patients who come in and they're bothering them? They said they don't like the appearance of them, they're having problems with hygiene. What about the skin tags or even hemorrhoids in Crohn's patients? How do you figure that out?

Luca Stocchi: Many patients come in with the idea that they can be removed, and I warn them against it because in Crohn's disease healing can be a problem. While it's not always a problem, it has to be considered when assessing more aggressive operative options. Again, it’s one of those situations where it’s not easy to find the optimal treatment, and it's more an issue of controlling symptoms rather than resolve incompletely the condition. Injection of long-acting steroid solutions can be helpful and some patients do have them and do have them repeatedly. But I think that their symptoms tend to improve when management is successful. Medical management is the most important issue in this particular subset of patients. Most of the time it has an intermittent nature, so sometimes more symptomatic than others. But again I would say from a surgical standpoint we should be very prudent and not excise systematically this large skin tag because they can result in an unhealed wound that is even more painful than the skin tag themselves. Generally, I refrain from excising them.

Scott Steele: Luca, I have two patient questions: They said that they had perianal Crohn’s disease, and one of the patients said that they had to have a bag for just perianal Crohn's disease. And I had another patient that said they had to have their rectum removed and a permanent bag for perianal Crohn's disease. Is this really the case? Can this happen, and if so, how often does this occur?

Luca Stocchi: It is entirely possible and it does occur in the most aggressive presentations of perianal Crohn's disease. Now when we look at the literature on perianal Crohn's disease and the issues of how often it's necessary to have a bag, I would say if we consider perianal disease alone, this is unusual. It’s not impossible, but it is unusual. But what is not completely clear in the literature when assessing patients with perianal Crohn's disease is what is the burden of associated bowel disease in particularly associated inflammation of the rectum?

And those are the cases that most of the time lead to permanent ileostomy, which can be either permanent ileostomy after removal of the rectum, or an ileostomy which is simply a deviation of the flow of the intestinal content, leaving the rectum in place, as we say, stoma diversion. These are rare. They are not common when considering all the patients that have perianal Crohn's disease at a given time. But those who have significant inflammation of the rectum associated or not with perianal Crohn's disease may require this unfortunately drastic surgical option.

Scott Steele: What are the complications that can occur with perianal Crohn’s disease?

Luca Stocchi: The most challenging complications are infections of the areas that are poorly controlled. So it can progress to infections that can involve the rectum, that can make the rectum impossible to use. Rarely, but very seriously, they could end up involving the bone surrounding the rectum. There are rare, but very hard, cases of osteomyelitis of the coccyx, or in rare cases of the sacrum, which is very difficult to treat. I think that the aggressiveness of perianal Crohn's disease can also lead to functional problems – the inability to control stools, fecal incontinence and therefore poor quality of life.

Scott Steele: Can perianal Crohn's disease develop into cancer?

Luca Stocchi: It is possible, and it is a recognized long-term complication. It's important that somebody with perianal Crohn's disease has a doctor that is familiar with this condition, who examines them periodically. I think that especially in perianal Crohn's disease that has been there for several years, it is possible to develop cancers, sometime cancer of the skin, sometimes the type of cancer that would originate from the rectum, but still in the perianal Crohn's disease. When the educated eye sees areas that are harder to have a particular aspect that is not suggestive of simple fistula, it's important to do the biopsy again. This is not a common complication, but as you point out, this is certainly a possible complication of perianal Crohn's disease.

Scott Steele: If you were to sum up some quick take home points for our listeners out there about perianal Crohn's disease, what would your points be?

Luca Stocchi: Do not ignore it, seek a specialist and then expect this as a problem that, unfortunately, the patient needs to live with. It is not possible to cure it, as of now. But I think it is possible to control it, control the symptoms, control the complications, treat the complications and hopefully allow most of the patients an appropriate and enjoyable quality of life.

Scott Steele: We like to end up with our guests some quick hitters. Number one, what's your favorite sport?

Luca Stocchi: Basketball.

Scott Steele: Number two, favorite meal?

Luca Stocchi: Pizza.

Scott Steele: What's the last book that you read?

Luca Stocchi: Underground Airlines by Ben Webster.

Scott Steele:  And what do you like about living here in Cleveland?

Luca Stocchi: A family-oriented town. A lot to do, good people. And I like my workplace.

Scott Steele: For more information about Cleveland Clinic's Digestive Disease and Surgery Institute please visit clevelandclinic.org/digestive. To make an appointment with a Cleveland Clinic digestive specialist please call 216.444.7000. Luca, thanks so much for joining us on Butts & Guts.

Luca Stocchi: Thank you for having me.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.