The Blueprint of a Septic Perianal Crohn's Disease Care Plan

Patients with septic perianal Crohn’s disease have infected abscesses that are difficult to treat.

Crohn’s disease affects about 700,000 individuals in the United States, with a serious complication called septic perianal Crohn’s disease occurring in 40% of patients.

Since treatment options for this condition lack in efficacy, researchers from Penn State College of Medicine have developed the first published medical and surgical approach care plan for managing this disease. Patients with septic perianal Crohn’s disease have infected abscesses that develop into fistulas, and are notoriously hard to treat.

The condition was typically treated with surgery, until the introduction of the immunosuppressant drug infliximab in 1998. Although earlier studies of infliximab demonstrated a response rate of up to 60%, only 25% of patients continued to experience healing after a year on the medication.

“What was thought to be a silver bullet of sorts for this problem really is not,” said researcher Walter A. Koltun.

Despite these numbers, a majority of patients will continue to take this expensive medication, because they themselves and their physicians fear the condition will worsen if the medication is stopped, according to a press release. After more than a decade of investigating a better treatment plan based on patient care outcomes and using medicine coordinated with surgery, researchers finally published their results in the Journal of the American College of Surgeons.

“What we did with this study is look at a combined medical and surgical protocol for managing this problem, recognizing that there’s a role for the medicines, and there’s a role for the surgery,” Koltun said. “Although this is acknowledged by most surgeons and gastroenterologists, no one had written down a protocol to follow that is predictable in its outcome.”

Researchers analyzed 135 cases of septic perianal Crohn’s disease treated at the hospital using this protocol, and found a 60% rate of healing that lasted at least 6 months, using a combined medical and surgical approach. For the remaining 40% of patients, half did not heal and needed a permanent ostomy bag, and the other half saw some improvements, but did not heal completely.

Additionally, researchers analyzed single nucleotide polymorphisms (SNPs) to see if any predicted healing. Certain SNPs did emerge, which have been suggested in other studies to play a role in septic perianal Crohn’s disease, however the results were not statistically significant.

“We’re gaining some sense of confidence that there are a certain number of genes that, if adversely affected, predispose patients toward having this problem and possibly not healing well,” Koltun said.

Koltun noted multi-center studies that include a greater number of patients and have greater statistical power are needed to gain further information on genetic factors in this disease. Furthermore, he hopes that this care plan will help patients receive treatment in a more consistent manner.

“… In a way that then allows the physician and the patient some confidence in regard to the outcome,” Koltun said.

Also, the protocol will provide physicians and patients with clearer guidance on when it makes sense to stop the drug and opt for surgery instead.

“Our protocol provides a paradigm for when you perhaps should stop the drug and when to consider surgery with or without medication,” Koltun said.