Perianal Fistual Prior To Crohn’s Disease Diagnosis Impacts Multiple Outcomes

Photo Credit: AndreyPopov

Longer time to Crohn’s disease diagnosis occurs among patients who have a perianal fistula as a manifesting sign and is associated with poorer outcomes.

Prolonged time to diagnosis among patients with Crohn’s disease who have a perianal fistula (PAF) as a manifesting sign is associated with poorer long-term outcomes, according to findings published in the Journal of Crohn’s and Colitis.

Up to one-third of patients with Crohn’s disease have one or more PAF during the course of the illness, according to Christianne Buskens, PhD, and colleagues. For 20% of those patients, PAF is the first manifestation of disease, but it may take many more years before the diagnosis of Crohn’s disease becomes evident, they noted.

The researchers conducted a multicenter, retrospective study that included patients with Crohn’s disease and a PAF preceding Crohn’s disease diagnosis. Time to Crohn’s disease diagnosis and its correlation with long-term outcomes served as the primary outcome.

Shortest Time to Diagnosis Seen With Radiological Healing

The analysis included 126 patients (48.8% men). Median age at first PAF manifestation was 24.0 years (interquartile range [IQR], 18.0-33.3) and the median age at the time of Crohn’s disease diagnosis was 27.0 (IQR, 21.0-37.0).

Overall, the median time to Crohn’s disease diagnosis was 15.0 months (IQR, 3.8-47.3).

Across the entire study population, 49 patients (38.9%) had a clinically closed fistula. The median time to clinical closure was 46 months (IQR, 25.0-91.0). Less than half of the patients with clinically closed fistulas (n=21; 42.9%) achieved radiological healing at a median of 39.0 months (IQR, 21.0-93.5).

Defunctioning for therapy-refractory fistulizing disease occurred in 25 patients (19.8%), and nine of these patients (36.0%) required an additional proctectomy. In this group with defunctioning, the median time to Crohn’s disease diagnosis was more than twice as long as patients without such circumstances (30.0 vs 12.0 months; P=0.054).

The shortest median time to Crohn’s disease diagnosis was seen for patients with radiological healing (4.0 months; IQR, 2.0-16.5) or clinical closure with no radiological healing (11.0 months; IQR, 3.0-47.8). Among patients with no fistula closure (n=51), the median time to Crohn’s disease diagnosis was significantly longer than in patients with fistula closure (18.0 vs 8.0 months; P=0.031).

Increasing Awareness & Conducting Future Research

Dr. Buskens and colleagues noted that, while the median time to Crohn’s disease diagnosis was 15 months for patients with a PAF at presentation, the upper end of the range for diagnosis extended to 4 years. The researchers also emphasized the impact of both good and poor outcomes, such as clinical closure and proctectomy.

“These results emphasize the need for clinical awareness [of underlying Crohn’s disease for patients with PAF], as a prolonged time to diagnosis is associated with worse outcomes,” the researchers wrote. “Our data suggest that, in order to achieve radiological healing, it is crucial to diagnose [Crohn’s disease] within the first months after fistula presentation.”

The authors also emphasized the need for clinical decision tools, including easy to use algorithms, for early identification of patients at risk for Crohn’s disease.

“Further research is needed to validate these results in a prospective study and to develop a method for early identification of patients at risk for having [Crohn’s disease] presenting with a PAF,” Dr. Buskens and colleagues wrote.