Review article: medical, surgical and radiological management of perianal Crohn's fistulas

Aliment Pharmacol Ther. 2011 Jan;33(1):5-22. doi: 10.1111/j.1365-2036.2010.04486.x. Epub 2010 Oct 29.


Background: Crohn's anal fistulas are common and cause considerable morbidity. Their management is often difficult; medical and surgical treatments rarely lead to true healing with frequent recurrence and complications.

Aim: To examine medical treatments previously and currently used, surgical techniques and the important role of optimal imaging.

Methods: We conducted a literature search in the Pub Med database using Crohn's, Anal Fistula, Surgery, Imaging and Medical Treatment as search terms.

Results: Antibiotics and immunosuppressants have a role, but slow initial response, side effects and relatively low remission rates of up to around a third with frequent recurrence limit their value. Long-term infliximab produces clinical remission in 36-58% of patients with combined medical and surgical management achieving optimal outcomes. Traditional and newer surgical procedures often have a high rate of recurrence with a significant risk of temporary or, in up to 10% of cases, permanent stomas, incontinence and unhealed or slowly healing wounds in 30%.

Conclusions: Management of Crohn's anal fistulas remains challenging. Established principles are to drain infection, use setons as required, aggressively manage active proctitis, give antibiotics, immunosuppressants and employ anti-TNFα therapy, and they demand significant co-operation between gastroenterologists and surgeons.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Anti-Bacterial Agents / therapeutic use*
  • Antibodies, Monoclonal / therapeutic use*
  • Combined Modality Therapy
  • Crohn Disease* / complications
  • Crohn Disease* / diagnosis
  • Crohn Disease* / drug therapy
  • Crohn Disease* / surgery
  • Gastrointestinal Agents / therapeutic use*
  • Humans
  • Immunosuppressive Agents / therapeutic use*
  • Infliximab
  • Magnetic Resonance Imaging / methods
  • Rectal Fistula / etiology
  • Rectal Fistula / surgery
  • Recurrence
  • Risk Factors
  • Treatment Outcome
  • Wound Healing


  • Anti-Bacterial Agents
  • Antibodies, Monoclonal
  • Gastrointestinal Agents
  • Immunosuppressive Agents
  • Infliximab