Elaboration and validation of Crohn’s disease anoperineal lesions consensual definitions

Table 1 Initial proposed definitions submitted for the first vote and the results of the agreement for those propositions

Lesions and descriptors	Definitions submitted to the votes	Agreement scores1
Ulceration	Skin or mucosal defect	8.7 (8-9)2
Depth
Deep or cavitating	Visible muscular and/or granulation tissue and/or undermined and inflammatory edges	8 (7-9)2
Superficial	Which is not deep	7.7 (7-9)2
Location
Anal canal and anal margin	Visible after unfolding the anal radial folds	7 (1-9)
Anal margin	Anal external edges	7.9 (5-9)
Perianal	Outside the anus radial folds	8.6 (6-9)
Extension
Extensive	≥ 5 mm	5.6 (1-9)3
Limited	< 5 mm	5.6 (1-9)3
Skin tag	Tense nodular lesion with granulomatous but not papillomatous aspect	4.8 (2-9)3
Activity
Inflammatory	Edematous aspect	6 (3-9)3
Non inflammatory	Fibrous aspect	6.2 (3-9)3
Perianal skin lesions
Papula	Visible and elevated palpable lesion < 2 cm in diameter	8 (6-9)
Node	Nodular cutaneous elevation, visible and/or palpable, diameter ≥ 2 cm	6.1 (1-9)
Edema	Swollen area	6 (3-7)3
Erythema	Redness
Pustula	Raised, visible and palpable lesion, with cloudy fluid content	8.2 (6-9)
Abscess	Swollen red skin, sometimes surrounded by necrosis area and which can release pus	6.5 (5-9)
Fistulae
Complexity
Complex	Recto-vaginal fistula or multiple external openings or abscess or remote external opening	6.6 (4-9)
Simple	Single external opening, next to anal margin, without abscess	6.3 (3-9)3
Note	Inspection alone can sometimes confirm the diagnosis of a complex fistula	9 (9-9)3
	Inspection alone cannot establish a diagnosis of simple fistula with certainty	8 (6-9)3
Drainage
Well drained	No abscess, no visible discharge and non-inflammatory external openings	7.6 (5-9)
Poorly drained	Inflammatory external opening(s) and/or abscess	7.4 (4-9)
External opening(s)
Inflammatory	Erythematous surrounded skin and budding port(s) with undermined edges	8.5 (7-9)2
Scar appearance	Fibrous and retracted aspect of the anal margin	7.8 (6-9)
	Deformed anus	7.8 (5-9)

¹Median and distribution;

²Definitions with strong agreement;

³Missing data.

Table 2 Consensual definitions and agreement scores

Lesions and descriptors	Consensual definitions	Agreement scores1
Ulceration	Skin or mucosal defect	8.7 (8-9]3
Depth
Superficial	Which is not deep	8 (7-9)3
Deep	Visible muscular and/or granulation tissue and/or undermined and inflammatory edges	7.7 (7-9)3
Cavitating	Deep decaying and destructive ulceration	8.6 (8-9)
Localisation
Anal canal	Visible after unfolding the anus radial folds	8.5 (7-9)
Anal margin	Anal external edges	8.5 (7-9)
Perianal	Outside the anus radial folds	9
Extension
Number		8.6 (8-9)
Percentage of ulcerated area	< 25%, 26-50%, > 50% of the anal circumference	8.3 (5-9)
Skin tag	Skin thickening of the anus	7.2 (3-9)
Activity
Inflammatory	Oedematous, swollen, tense	8 (4-9)
Non inflammatory	Fibrous, firm and non-oedematous aspect	8.7 (2-9)
Ulcerated (vs not)	Ulceration on the skin tag (vs no ulceration on the skin tag)	7.8 (2-9)
Perianal skin lesions
Papula	Elevated, circumscribed and solid lesion without liquid content	8.1 (6-9)
Node2	Elevated, nodular and protruding lesion, impression of deep extension	7.8 (6-9)
Oedema	Swollen appearance	8.2 (7-9)
Erythema	Flat redness	8.3 (5-9)
Abscess	Swollen red skin, which may be surrounded by necrosis area and which can release pus	8.3 (7-9)
Fistula
Complexity	AGA’s definitions (3)
	It is possible to recognize that a fistula is complex by inspection alone	7.2 (1-9)
	Inspection alone is not always sufficient to reliably recognize that a fistula is simple	8.5 (7-9)
Drainage
Well drained	Absence of abscess, of purulent discharge an non inflammatory external opening(s)	7.8 (5-9)
Poorly drained	Inflammatory external opening(s) and/or abscess and/or spontaneous purulent discharge	7.5 (5-9)
	Poor drainage of a fistula can be diagnosed by inspection alone	8.6 (7-9)
	Inspection alone is often not sufficient to be certain that a fistula is well drained	7.6 (1-9)
External opening
Inflammatory	Erythematous surrounded skin and budding port(s) with undermined edges	Validated by vote 1
Scar appearance	Deformed anus with fibrous aspect and/or retractile appearance of the anal margin	7.6 (8-9)
	With inflammatory activity or not	7.6 (3-9)

¹Median and distribution;

²Validated by vote 1;

³All definitions obtained a strong agreement except the entity “node”.