Management of Severe, Refractory Crohn's Disease with Complex Perianal Fistula and Malnutrition

Immediate Emergency Management

The American Society of Colon and Rectal Surgeons recommends performing urgent surgical drainage of the perianal abscess under general anesthesia without wound packing in patients with severe, refractory Crohn's disease and complex perianal fistula 1, 2.
The European Crohn's and Colitis Organisation suggests not actively searching for or probing the fistula tract during initial abscess drainage, as this can create iatrogenic tracts and increase complexity 1, 2.
The World Journal of Emergency Surgery advises placing a loose draining seton if an obvious fistula is present without probing, but not laying open the fistula tract 1, 2.
Assessing the rectum during abscess drainage to evaluate for proctitis is crucial, as this influences subsequent management 1.

Creating a temporary diverting ileostomy is recommended given the severity of disease, profound malnutrition, and complex perianal sepsis, as suggested by the World Journal of Emergency Surgery 3, 1.
The Journal of Crohn's and Colitis recommends that the ileostomy allows control of luminal disease, promotes fistula healing by diverting fecal stream, and can be reversed once inflammation is controlled and nutritional status improves 4, 5.

The World Journal of Emergency Surgery suggests initiating broad-spectrum antibiotics covering gram-negative bacteria and anaerobes immediately, with appropriate regimens including metronidazole combined with a fluoroquinolone or third-generation cephalosporin 3, 6.
Continuing antibiotics for 5-7 days post-drainage, adjusting based on culture results and clinical response, is advised by the World Journal of Emergency Surgery 8, 6.

The World Journal of Emergency Surgery recommends initiating total parenteral nutrition immediately given profound malnutrition and the emergency surgical context 3, 6.
Continuing TPN until enteral nutrition becomes feasible, typically after control of sepsis and improvement in clinical status, is suggested by the World Journal of Emergency Surgery 6.

The Journal of Crohn's and Colitis advises initiating infliximab once the abscess is adequately drained and sepsis is controlled, as it is the most effective medical therapy for complex perianal fistulizing Crohn's disease 4, 5.
Combining infliximab with a thiopurine enhances efficacy in complex fistulizing disease, as recommended by the Journal of Crohn's and Colitis 4, 5.

The Journal of Crohn's and Colitis suggests continuing infliximab with thiopurine as maintenance therapy along with seton drainage, which should be maintained long-term 4, 5.
Monitoring clinical response by decreased fistula drainage is usually sufficient in routine practice, as advised by the Journal of Crohn's and Colitis 4, 5.

The Journal of Crohn's and Colitis recommends planning ileostomy reversal only after control of luminal inflammation, significant improvement or closure of perianal fistula, restoration of nutritional status, and stable maintenance on anti-TNF therapy for at least 3-6 months 4, 5.

The World Journal of Emergency Surgery advises never probing aggressively for fistula tracts during emergency abscess drainage, as this creates iatrogenic complexity 1, 2.
The Journal of Crohn's and Colitis suggests avoiding fistulotomy in Crohn's disease, as this leads to poor healing and potential incontinence 4, 5.
The World Journal of Emergency Surgery recommends avoiding starting immunosuppressive therapy before adequate drainage of sepsis 6.
The Journal of Crohn's and Colitis advises against attempting primary anastomosis in this setting with multiple risk factors 1.
The World Journal of Emergency Surgery suggests never attempting definitive fistula closure procedures in the emergency setting or in the presence of active proctitis 4, 5, 2.