#MondayNightIBD Aline Charabaty, MD, FACG, AGAF Takeda JanssenUS David Schwartz Amy Lee Lightner, MD David Schwartzberg, MD Stefan Holubar MD MS Seb Antonino Spinelli Fernando Gomollón Bram Verstockt Gianluca Pellino Julio Mayol 22y/o w crohns ileitis in endo remission on IFX, develop perianal abscess & fistula. Abscess drained & #seton placed in mid-transphincteric #Fistula . 
3 months later, he has minimal drainage, no pain
IFX TL 16, no ATI
#MondayNightIBD what’s the next step?
(🔑d/c =remove)

#PreConvo #IBDPoll1️⃣

🆓 #CME 👉🏽bit.ly/FleshnerPre

55yo, new Dx #Crohns colitis & #perianal abscess. Abscess drained & seton is placed. She is in your office few days later & you discuss starting IFX.

🎯She asks how long she needs to keep the #seton
You recommend?

#PreConvo #IBDPoll2️⃣

🆓 #CME 👉🏽bit.ly/FleshnerPre

In the RCT NEJM 1999, assessing the efficacy of IFX induction doses (0,2,6 weeks) in reducing #draining #fistula (DF) in perianal #Crohns #CPF

🔺How was the primary efficacy end point defined?

#PreB2B #IBDPoll1️⃣

🆓 #CME 👉🏽 bit.ly/PerianalDisPre

How often do #PerianalFistula #CPF complications affect patients with #Crohns disease?

#PreB2B #IBDPoll2️⃣

🆓 #CME 👉🏽 bit.ly/PerianalDisPre

57 y/o recent dx #Crohns ileum + rectum presents w perianal fistula + abscess . What treatment(s) will optimize the chance of #CPF #Fistula healing?

#MondayNightIBD 4/Welcome #GITwitter #IBDTwitter to another 🔥 #MondayNightIBD #Back2Basics !

Let’s talk #Perianal Fistula in #Crohns #CPF

☑️ Incidence
☑️ Classification
☑️ Diagnosis
☑️ Initial therapy

#MondayNightIBD 5/ #CPF #Incidence & #Prevalence
➡️Can be isolated (w/o luminal dis)
➡️Initial presentation in 10-17%
➡️Affects 30-40% of CD pts
➡️Prevalence varies by CD location, rectal disease=risk factor

#MondayNightIBD Jean-Frederic Colombel Oriana M. Damas, MD Erin Forster MD MPH Morgan Sendzischew Shane, MD Jennifer Seminerio @Dr. Samir A Shah SandraQuezadaMD Parambir Dulai Cristina Flores M.D. PhD Yi Yuan Tan 6/ #CPF #Classification
💠Simple: Does not cross the sphincter complex, 1⃣ external opening
💠Complex: Inter/Trans/supra/intra sphincteric, > 1⃣ opening +/- Abscess/stricture/ Rectovaginal fistula

#B2BPearl : #CPF Often complex!
Complex fistula assoc w⬇️remission &⬆️recurrence

#MondayNightIBD Jean-Frederic Colombel Oriana M. Damas, MD Erin Forster MD MPH Morgan Sendzischew Shane, MD Jennifer Seminerio @Dr. Samir A Shah SandraQuezadaMD Parambir Dulai Cristina Flores M.D. PhD Yi Yuan Tan Noa Krugliak Cleveland, MD Jeff Ko, MD Asad ur Rahman, MD, FACP Alexa Weingarden MD PhD Taku Kobayashi Dr. Mohamed Alboraie MD. FRCP Rishika Chugh Maria T. Abreu Beth-Ann Norton, MS, RN, ANP-BC 7/New Consensus #CPF Classification
💠Stratification according to CPF severity & outcome
💠Goals is to guide decision making in trials & practice
💠Take into account: Fistula anatomy+ presence of luminal dis + symptoms burden/QO

#MondayNightIBD Jean-Frederic Colombel Oriana M. Damas, MD Erin Forster MD MPH Morgan Sendzischew Shane, MD Jennifer Seminerio @Dr. Samir A Shah SandraQuezadaMD Parambir Dulai Cristina Flores M.D. PhD Yi Yuan Tan Noa Krugliak Cleveland, MD Jeff Ko, MD Asad ur Rahman, MD, FACP Alexa Weingarden MD PhD Taku Kobayashi Dr. Mohamed Alboraie MD. FRCP Rishika Chugh Maria T. Abreu Beth-Ann Norton, MS, RN, ANP-BC Severine Vermeire Jordan Axelrad, MD, MPH “Get Screened” King-Mullins, MD Dorna Jafari, MD, FACS, FASCRS David Liska Thomas Read Sean Langenfeld Dhaval Patel Mark Soliman, MD, FACS, FASCRS jeremielefevre 8/ #MondayNightIBD #CPF #Diagnosis

🟡History and PE (perianal pain, discharge, fever)
🟡Imaging (MRI > CT) or rectal EUS
🟡➕ EUA (diagnostic+therapeutic for drainage +/- seton)

#MondayNightIBD Jean-Frederic Colombel Oriana M. Damas, MD Erin Forster MD MPH Morgan Sendzischew Shane, MD Jennifer Seminerio @Dr. Samir A Shah SandraQuezadaMD Parambir Dulai Cristina Flores M.D. PhD Yi Yuan Tan Noa Krugliak Cleveland, MD Jeff Ko, MD Asad ur Rahman, MD, FACP Alexa Weingarden MD PhD Taku Kobayashi Dr. Mohamed Alboraie MD. FRCP Rishika Chugh Maria T. Abreu Beth-Ann Norton, MS, RN, ANP-BC Severine Vermeire Jordan Axelrad, MD, MPH “Get Screened” King-Mullins, MD Dorna Jafari, MD, FACS, FASCRS David Liska Thomas Read Sean Langenfeld Dhaval Patel Mark Soliman, MD, FACS, FASCRS jeremielefevre Mario Trejo-Avila Robin Phillips FRU, St Mark's Richard Brady Kat Baker 💙 (née Gash) Bassem Matta M.D. Dr.Ajab khan Fasiha Kanwal Reena Chokshi, MD Jeremy Glissen Brown MD, MSc Ali Soroush, MD, MS 9/ #MondayNightIBD
🎯 #CPF Management

👉Control infection
👉Treat rectal🔥/stricture
👉Heal fistula
(✅Definition of response & remission👇)
👉Prevent recurrence
👉Improve quality of life

#MondayNightIBD Jean-Frederic Colombel Oriana M. Damas, MD Erin Forster MD MPH Morgan Sendzischew Shane, MD Jennifer Seminerio @Dr. Samir A Shah SandraQuezadaMD Parambir Dulai Cristina Flores M.D. PhD Yi Yuan Tan Noa Krugliak Cleveland, MD Jeff Ko, MD Asad ur Rahman, MD, FACP Alexa Weingarden MD PhD Taku Kobayashi Dr. Mohamed Alboraie MD. FRCP Rishika Chugh Maria T. Abreu Beth-Ann Norton, MS, RN, ANP-BC Severine Vermeire Jordan Axelrad, MD, MPH “Get Screened” King-Mullins, MD Dorna Jafari, MD, FACS, FASCRS David Liska Thomas Read Sean Langenfeld Dhaval Patel Mark Soliman, MD, FACS, FASCRS jeremielefevre Mario Trejo-Avila Robin Phillips FRU, St Mark's Richard Brady Kat Baker 💙 (née Gash) Bassem Matta M.D. Dr.Ajab khan Fasiha Kanwal Reena Chokshi, MD Jeremy Glissen Brown MD, MSc Ali Soroush, MD, MS Dr Brian Bressler Laura Targownik 🏳️‍⚧️👩🏼‍⚕️ Eric Benchimol Vipul Jairath MBChB DPhil Gil Kaplan MD MPH Bram Verstockt Parul Tandon Seth Shaffer Laurent Peyrin-Biroulet Sun-Ho Lee MD PhD 10/ #MondayNightIBD Complex #CPF Initial Management
1⃣ EUA: Abscess drainage+Seton

2⃣ Abx: Cipro>Flagyl. Prolonged course w biologics: ⬇️drainage,⬆️CPF response

3⃣ IFX typically 1st choice +/-AZA

💎 #B2BPearl No fistulotomy in complex CPF !
💎Optimize strategy to ⬆️response👇

#MondayNightIBD Jean-Frederic Colombel Oriana M. Damas, MD Erin Forster MD MPH Morgan Sendzischew Shane, MD Jennifer Seminerio @Dr. Samir A Shah SandraQuezadaMD Parambir Dulai Cristina Flores M.D. PhD Yi Yuan Tan Noa Krugliak Cleveland, MD Jeff Ko, MD Asad ur Rahman, MD, FACP Alexa Weingarden MD PhD Taku Kobayashi Dr. Mohamed Alboraie MD. FRCP Rishika Chugh Maria T. Abreu Beth-Ann Norton, MS, RN, ANP-BC Severine Vermeire Jordan Axelrad, MD, MPH “Get Screened” King-Mullins, MD Dorna Jafari, MD, FACS, FASCRS David Liska Thomas Read Sean Langenfeld Dhaval Patel Mark Soliman, MD, FACS, FASCRS jeremielefevre Mario Trejo-Avila Robin Phillips FRU, St Mark's Richard Brady Kat Baker 💙 (née Gash) Bassem Matta M.D. Dr.Ajab khan Fasiha Kanwal Reena Chokshi, MD Jeremy Glissen Brown MD, MSc Ali Soroush, MD, MS Dr Brian Bressler Laura Targownik 🏳️‍⚧️👩🏼‍⚕️ Eric Benchimol Vipul Jairath MBChB DPhil Gil Kaplan MD MPH Bram Verstockt Parul Tandon Seth Shaffer Laurent Peyrin-Biroulet 11/ In Summary : #Crohns #Perianal #Fistula
🔺Challenging complications, affecting up to 40% of pts
🔺Often complex & require MultiD care
🔺Combo medical+ surgical Rx

✅Proposed #CPF Management👇 Journal of the Canadian Assn of Gastroenterology doi.org/10.1093/jcag/g…

#MondayNightIBD Jean-Frederic Colombel Oriana M. Damas, MD Erin Forster MD MPH Morgan Sendzischew Shane, MD Jennifer Seminerio @Dr. Samir A Shah SandraQuezadaMD Parambir Dulai Cristina Flores M.D. PhD Yi Yuan Tan Noa Krugliak Cleveland, MD Jeff Ko, MD Asad ur Rahman, MD, FACP Alexa Weingarden MD PhD Taku Kobayashi Dr. Mohamed Alboraie MD. FRCP Rishika Chugh Maria T. Abreu Beth-Ann Norton, MS, RN, ANP-BC Severine Vermeire Jordan Axelrad, MD, MPH “Get Screened” King-Mullins, MD Dorna Jafari, MD, FACS, FASCRS David Liska Thomas Read Sean Langenfeld Dhaval Patel Mark Soliman, MD, FACS, FASCRS jeremielefevre Mario Trejo-Avila Robin Phillips FRU, St Mark's Richard Brady Kat Baker 💙 (née Gash) Bassem Matta M.D. Dr.Ajab khan Fasiha Kanwal Reena Chokshi, MD Jeremy Glissen Brown MD, MSc Ali Soroush, MD, MS Dr Brian Bressler Laura Targownik 🏳️‍⚧️👩🏼‍⚕️ Eric Benchimol Vipul Jairath MBChB DPhil Gil Kaplan MD MPH Bram Verstockt Parul Tandon Seth Shaffer Laurent Peyrin-Biroulet Journal of the Canadian Assn of Gastroenterology 12/ #MondayNightIBD
#PostConvo #IBDPoll 1️⃣
🆓 #CME 👉🏼bit.ly/PerianalDisPost

How often do #PerianalFistula #CPF affect patients with #Crohns disease?

#MondayNightIBD Jean-Frederic Colombel Oriana M. Damas, MD Erin Forster MD MPH Morgan Sendzischew Shane, MD Jennifer Seminerio @Dr. Samir A Shah SandraQuezadaMD Parambir Dulai Cristina Flores M.D. PhD Yi Yuan Tan Noa Krugliak Cleveland, MD Jeff Ko, MD Asad ur Rahman, MD, FACP Alexa Weingarden MD PhD Taku Kobayashi Dr. Mohamed Alboraie MD. FRCP Rishika Chugh Maria T. Abreu Beth-Ann Norton, MS, RN, ANP-BC Severine Vermeire Jordan Axelrad, MD, MPH “Get Screened” King-Mullins, MD Dorna Jafari, MD, FACS, FASCRS David Liska Thomas Read Sean Langenfeld Dhaval Patel Mark Soliman, MD, FACS, FASCRS jeremielefevre Mario Trejo-Avila Robin Phillips FRU, St Mark's Richard Brady Kat Baker 💙 (née Gash) Bassem Matta M.D. Dr.Ajab khan Fasiha Kanwal Reena Chokshi, MD Jeremy Glissen Brown MD, MSc Ali Soroush, MD, MS Dr Brian Bressler Laura Targownik 🏳️‍⚧️👩🏼‍⚕️ Eric Benchimol Vipul Jairath MBChB DPhil Gil Kaplan MD MPH Bram Verstockt Parul Tandon Seth Shaffer Laurent Peyrin-Biroulet Journal of the Canadian Assn of Gastroenterology 13/ #MondayNightIBD
#PostConvo #IBDPoll 2️⃣
🆓 #CME 👉🏼bit.ly/PerianalDisPost

57 y/o w recent diagnosis of #Crohns ileum + rectum presents with perianal fistula + abscess . What treatment(s) will optimize chance of fistula healing?