Pediatric Crohnâ??s patients with perianal disease have worse prognosis

Last Updated: 2017-06-21

By Will Boggs MD

NEW YORK (Reuters Health) - Pediatric patients with Crohn’s disease have worse clinical outcomes when they have perianal disease, researchers from Israel report.

“Both fistulizing and nonfistulizing perianal disease were predictors of worse outcomes, including more complicated disease, over time,” Dr. Amit Assa from Schneider Children’s Hospital, Tel-Aviv University, in Petach-Tikva, Israel, told Reuters Health by email. “The presence of nonfistulizing disease at diagnosis was a significant risk factor for the development of fistulizing perianal disease.”

About 30% of patients with Crohn's disease will develop perianal disease, which, in adults, is associated with a more complicated course. Whether this is true for pediatric disease has remained unclear.

To investigate, Dr. Assa and colleagues conducted a retrospective study of 296 pediatric patients diagnosed with Crohn's disease. More than a third of the patients had perianal involvement, including 24% with nonfistulizing perianal disease and 13.5% with fistulizing perianal disease

Perianal involvement, especially nonfistulizing disease, was more common in girls than in boys, the researchers report in Inflammatory Bowel Diseases, online June 5.

Patients with perianal disease were more likely than others to receive maintenance immunomodulatory treatment and anti-TNF treatment, and their time to initiation of biological treatment was significantly earlier.

Median time to first disease flare did not differ significantly between patients with no perianal disease, nonfistulizing perianal disease, or fistulizing perianal disease. But those with perianal disease were significantly more likely to require hospitalization at some point after their initial diagnosis.

By the end of a median follow-up of 8.5 years, the rate of complicated disease (structuring or internal fistulizing) was significantly increased in the nonfistulizing (50%) and fistulizing (55%) patients, compared with patients without perianal disease (31%).

Moreover, patients with nonfistulizing perianal disease at diagnosis were 3.4 times more likely than those without perianal disease to go on to develop perianal fistulae.

“As disease tends to be more severe over time in patients with perianal disease and one of the treatment aims is to avoid disease's complications, it is implied that early aggressive therapy (anti-TNF, mainly) might potentially alter the long-term natural history of more complications in these patients,” Dr. Assa said.

“Patients with nonfistulizing perianal disease should be followed closely for the development of fistulizing perianal disease and patients with both fistulizing and nonfistulizing disease should be treated with anti-TNFs early in the course of disease,” he concluded.

Dr. Jacob Langer from the Hospital for Sick Children in Toronto, Canada, recently reviewed the operative management of complex perianal Crohn’s disease in children. He told Reuters Health by email, “There is a much smaller group of children who have very aggressive or complex perianal disease, and this population is really not addressed in this paper. Those children need a highly specialized and individualized approach to surgical management.”

Dr. Ahmed Nasr from Children's Hospital of Eastern Ontario, in Ottawa, Canada, who recently addressed the optimal surgical strategy for complex perianal fistulous disease in pediatric Crohn's, said, “There is a paucity of evidence in pediatric population when compared to adults.”

“Data from this study suggest that more aggressive treatment in patients with perianal disease may help to prevent the disease complications to which they are more prone,” he told Reuters Health by email.

SOURCE: http://bit.ly/2rBFsQT

Inflamm Bowel Dis 2017.