Fistulas: The Common Crohn’s Side Effect You Should Be Aware Of
When abnormal tunnels form in the wall of the intestine, it can lead to a serious infection. Here’s what you need to know about how to recognize and treat fistulas.
By Heather Lindsey
Medically Reviewed by Kareem Sassi, MD
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If you have Crohn’s disease, you already know that managing complications can sometimes be challenging. Fistulas — abnormal openings that form in the wall of the intestine and connect to other tissues or hollow organs — are one such example. Over time, fistulas can lead to pain and infection. But treatment options exist.
With Crohn’s disease, a deep ulcer or a sore in the inflamed intestinal tract can spread and tunnel into deeper tissues — most commonly in and around the anus — resulting in a perianal fistula. In fact, a review published in February 2015 in theWorld Journal of Gastroenterology found that 23 to 38 percent of people with Crohn’s develop perianal fistulas.
A perianal fistula may only become noticeable once it has broken through the skin surface, says Shannon Chang, MD, gastroenterologist and assistant professor of medicine at NYU Langone Medical Center in New York City. “These fistulas often become apparent around the buttocks area when there is pain with sitting, a palpable lump, or liquid or pus seeping onto underwear,” she says. Patients may also develop fevers.
If you suspect that a fistula has formed, alert your doctor and schedule a physical exam as a first step, says Jean Ashburn, MD, a colorectal surgeon who specializes in IBD at the Cleveland Clinic in Ohio. Following this, a Crohn’s disease specialist will schedule any necessary testing, which may include:
- Blood tests to detect infection
- Special imaging tests, such as computerized tomography (CT) scans or magnetic resonance imaging (MRI) scans to view the fistula
The surgeon may also want to perform an anoscopy, says Dr. Ashburn. This exam consists of inserting a small tubular instrument called an anoscope into the anus to view problems in the anal canal.
Treatment Options for Fistulas
If a fistula is small, antibiotics and other medical treatment may heal it, according to the Crohn’s & Colitis Foundation of America.
“Some older research shows that antibiotics are helpful,” says Adam Ehrlich, MD, MPH, assistant professor of medicine at the Lewis Katz School of Medicine at Temple University in Philadelphia.
But newer data supports the use of biologic drugs that block tumor necrosis factor alpha (TNF-alpha), a protein that can contribute to inflammation, adds Dr. Ehrlich. Examples include Remicade (infliximab) and Humira (adalimumab). “Anti TNF-alpha drugs have become the standard of care for the medical treatment of fistulas in Crohn’s disease patients,” he says.
The medication Stelara (ustekinumab), another biologic that targets proteins causing inflammation, may also be an option, though data on “a lot of patients hasn't been published yet,” says Ehrlich.
Some Crohn’s disease drugs that help with healing fistulas may be prescribed in combination with surgery, says Ashburn.
If Surgery Is Needed
Surgeons may decide to drain abscesses (under anesthesia) that they find during an exam. They may also place a seton, which is a heavy suture or latex loop, that prevents new abscesses from forming, says Dr. Chang. The seton typically stays in place for “months to years,” she says.
In severe cases, patients may benefit from having an ostomy to allow the anal area to rest and heal, says Ashburn. This procedure involves diverting the intestine to an opening on the abdomen called a stoma, where waste can drain into a bag. This surgery requires a short hospital stay and can be reversed after the anus heals. Or, “if the patient is happy with the ostomy, it can be kept for as long as he or she likes.”
Future Approaches to Treatment
A review published in June 2019 inStem Cell Research & Therapy shows that stem cells, which are cells that can transform into almost any type of tissue in the body, may be a viable treatment for fistulas one day, says Ehrlich. While still experimental, this approach typically involves taking stem cells from the patient’s fat tissue and creating a tissue plug that surgeons place in the fistula, enabling it to heal.
“There are new medications that become available each year that we hope will be more effective at controlling Crohn’s disease with fewer side effects,” says Ashburn, adding that surgeons are also exploring how to best treat patients with fistulas.
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