Published online Dec 21, 2016. doi: 10.3748/wjg.v22.i47.10380
Peer-review started: August 28, 2016
First decision: September 21, 2016
Revised: October 3, 2016
Accepted: October 31, 2016
Article in press: October 31, 2016
Published online: December 21, 2016
To characterize radiological and clinical factors associated with subsequent surgical intervention in Crohn’s disease (CD) patients with intra-abdominal fistulae.
From a cohort of 1244 CD patients seen over an eight year period (2006 to 2014), 126 patients were identified as having intra-abdominal fistulae, and included in the study. Baseline patient information was collected from the medical records. Imaging studies were assessed for: anatomic type and number of fistulae; diameter of the inflammatory conglomerate; length of diseased bowel; presence of a stricture with pre-stenotic dilatation; presence of an abscess; lymphadenopathy; and the degree of bowel enhancement. Multivariate analysis for the prediction of abdominal surgery was calculated via Generalized Linear Models.
In total, there were 193 fistulae in 132 patients, the majority (52%) being entero-enteric. Fifty-nine (47%) patients underwent surgery within one year of the imaging study, of which 36 (29%) underwent surgery within one month. Radiologic features that were associated with subsequent surgery included: multiple fistulae (P = 0.009), presence of stricture (P = 0.02), and an entero-vesical fistula (P = 0.01). Evidence of an abscess, lymphadenopathy, or intense bowel enhancement as well as C-reactive protein levels was not associated with an increased rate of surgery. Patients who were treated after the imaging study with combination immunomodulatory and anti-TNF therapy had significantly lower rates of surgery (P = 0.01). In the multivariate analysis, presence of a stricture [RR 4.5 (1.23-16.3), P = 0.02] was the only factor that increased surgery rate.
A bowel stricture is the only factor predicting an increased rate of surgery. Radiological parameters may guide in selecting treatment options in patients with fistulizing CD.
Core tip: We performed a longitudinal cohort study to identify radiological and clinical parameters that are associated with surgery within one-year of diagnosis of fistulae by cross-sectional imaging. We retrospectively reviewed 126 Crohn’s disease (CD) patients with intra-abdominal fistulae. Radiologic features that were associated with subsequent surgery included: multiple fistulae, presence of stricture, and an entero-vesical fistula. Evidence of an abscess, lymphadenopathy, or intense bowel enhancement was not associated with an increased rate of surgery. In multivariate analysis only the presence of a stricture was independently associated with an increased rate of surgery. These findings should be taken in to account when making therapeutic decisions for patients with fistulizing CD.