Crohn's disease: is there any link between anal and luminal phenotypes?

International audiencePURPOSE: Perianal Crohn's disease (CD) encompasses a variety of lesion similar to luminal disease, which are usually not distinctly assessed. Links between luminal and perianal CD phenotype remains therefore underreported, and we aimed to describe both luminal and perianal phenotype and their relationships. METHODS: From January 2007, clinical data of all consecutive patients with CD seen in a referral center were prospectively recorded. Data recorded until October 2011 were extracted and reviewed for study proposal. RESULTS: A total of 282 patients (M/F, 108/174; aged 37.8 ± 16.2 years) were assessed that included 154 cases (54.6 %) with anal ulceration, 118 cases (41.8 %) with fistula, 49 cases (17.4 %) with stricture, and 94 cases without anal lesion (33.3 %). Anal ulcerations were associated with fistulas (N = 87/154) in more than half of patients (56.5 %) and were isolated in 55 patients (35.7 %). Most of strictures (94 %) were associated with other lesions (N = 46/49). Harvey-Bradshaw score was significantly higher in patients with ulcerations (p \textless 0.001) as compared to those with perianal fistulas (p = 0.15) or with anal strictures (p = 0.16). Proportions of complicated behavior (fistulizing or stricturing) of luminal CD were similar according to anal lesions: anal fistulas were not significantly associated to penetrating Montreal phenotype (N = 4/31 p = 0.13) as well as anal stricture and stricturing Montreal phenotype (N = 3/49, p = 0.53). CONCLUSIONS: The phenotype of luminal disease does not link with the occurrence and the phenotype of perianal Crohn's disease. Anal ulcerations denote a more severe disease on both luminal and perianal locations and should consequently be taking into account in physician decision-makin

Easy clip to treat anal fistula tracts: a word of caution

International audienceBackground and aims: Closing the internal opening by a clip ovesco has been recently proposed for healing the fistula tract, but, to date, data on benefit are poorly analyzed. The aim was to report a preliminary multicenter experience. Materials and methods Retrospective study was undertaken in six different French centers: surgical procedure, immediate complications, and follow-up have been collected. Results Nineteen clips were inserted in 17 patients (M/F, 4/13; median age, 42 years [29–54]) who had an anal fistula: 12 (71 %) high fistulas (including 4 rectovaginal fistulas), 5 (29 %) lower fistulas (with 3 rectovaginal fistulas), and 6 (35 %) Crohn’s fistulas. Out of 17 patients, 15 had a seton drainage beforehand. The procedure was easy in 8 (47 %) patients and the median operative time was 27.5 min (20–36.5). Postoperative period was painful for 11 (65 %) patients. A clip migration was noted in 11 patients (65 %) after a median follow-up of 10 days (5.5–49.8). Eleven patients (65 %) who failed had reoperation including 10 new drainages within the first month (0.5–5). After a mean follow-up of 4 months (2–7),, closing the tract was observed in 2 patients (12 %) following the first insertion of the clip and in another one after a second insertion. Conclusion: Treatment of anal fistula by placing a clip on the internal opening is disappointing and deleterious for some patients. A better assessment before dissemination is recommended

Predictive Capability of Anorectal Physiologic Tests for Unfavorable Outcomes Following Biofeedback Therapy in Dyssynergic Defecation

The purpose of this study is to evaluate the predictive capability of anorectal physiologic tests for unfavorable outcomes prior to the initiation of biofeedback therapy in patients with dyssynergic defecation. We analyzed a total of 80 consecutive patients who received biofeedback therapy for chronic idiopathic functional constipation with dyssynergic defecation. After classifying the patients into two groups (responders and non-responders), univariate and multivariate analyses were performed to determine the predictors associated with the responsiveness to biofeedback therapy. Of the 80 patients, 63 (78.7%) responded to biofeedback therapy and 17 (21.3%) did not. On univariate analysis, the inability to evacuate an intrarectal balloon (P=0.028), higher rectal volume for first, urgent, and maximal sensation (P=0.023, P=0.008, P=0.007, respectively), and increased anorectal angle during squeeze (P=0.020) were associated with poor outcomes. On multivariate analysis, the inability to evacuate an intrarectal balloon (P=0.018) and increased anorectal angle during squeeze (P=0.029) were both found to be independently associated with a lack of response to biofeedback therapy. Our data show that the two anorectal physiologic test factors are associated with poor response to biofeedback therapy for patients with dyssynergic defecation. These findings may assist physicians in predicting the responsiveness to therapy for this patient population

Defecography

La défécographie est un examen radiologique permettant une évaluation fonctionnelle de la partie postérieure du pelvis. Le remplissage des cavités vaginale, rectale et iléale par un produit de contraste radiologique permet l'obtention de clichés dynamiques de ces organes pendant une défécation. Les principales informations apportées concernent à la fois la qualité de l'évacuation rectale et les anomalies de l'anatomie fonctionnelle telles que prolapsus rectal de haut grade, grande rectocèle, entérocèle ou anisme. Les autres « anomalies » doivent être retenues avec beaucoup de prudence parce qu'elles sont fréquemment observées chez les sujets asymptomatiques

Enterocele

L'entérocèle est une hernie intrapelvienne contenant des structures iléales. Elle est principalement (mais non exclusivement observée) après chirurgie pelvienne (hystérectomie). Les malades ayant une entérocèle souffrent de pesanteurs pelviennes et d'une procidence vaginale ou rectale. En revanche, les symptômes de dyschésie ou de constipation ne sont probablement pas secondaires à l'entérocèle. L'examen clinique sous-estime souvent la présence d'une entérocèle : son diagnostic repose de ce fait, sur une exploration radiologique comme la défécographie

Dyschesia

La dyschésie est fréquemment exprimée chez les malades qui souffrent de constipation. Cet ensemble de symptômes n'implique pas nécessairement un obstacle terminal d'évacuation. Après avoir éliminé une sténose ou un obstacle organique, les cliniciens ont besoin de recourir à des méthodes objectives visant à quantifier le trouble de l'évacuation rectale et à identifier les anomalies fonctionnelles associées (anisme, rectocèle)