Colorectal Quiz Episode 26: Perianal Crohn's Disease

Published: 2022-01-17

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Shimon Jacobs — host
Jason Friser — guest
Mark Levitt — host
Christine Velasco — guest
Lisa McMahon — guest

Chapters

0:05Introduction and Case Presentation — Host introductions and presentation of an 8-year-old male with 3 days of perianal pain, prior workup for IBD showing 30 cm of terminal ileal inflammation on MRE, now presenting with perianal abscess.
2:39Diagnostic Challenges in Crohn's Disease — Discussion of diagnostic pathways when colonoscopy cannot intubate the terminal ileum, including capsule endoscopy, fecal calprotectin, and the historical role of diagnostic laparoscopy. Addresses the clinical dilemma of initiating biologics without tissue diagnosis.
5:12Perianal Disease Epidemiology and Imaging — Discussion of whether combined terminal ileal and perianal disease is typical, with clarification that perianal disease is common in Crohn's and often the presenting feature in pediatric patients.
7:51Surgical Planning and Timing — Review of indications for operative intervention, the role of preoperative MRI pelvis, and algorithms for coordinating surgical drainage with endoscopic evaluation. Discussion of when imaging can be deferred to avoid treatment delay.
11:21Operative Findings and Technique — Description of intraoperative findings including skin tags, fissures, and spontaneous drainage at the dentate line. Detailed discussion of surgical technique including use of hydrogen peroxide to identify fistula tracts, seton placement principles, and avoidance of creating iatrogenic fistulas.
15:22Postoperative Course and Endoscopic Findings — Description of postoperative antibiotics, bowel preparation, and colonoscopy findings showing terminal ileitis with erythema and friability. Review of clinical red flags including skin tags, fissures, chronic diarrhea, and growth curve deceleration.
16:46Timing of Immunosuppression and Seton Management — Discussion of protocols for initiating biologics after source control of infection, typical seton duration of at least 6 months, criteria for seton removal including clinical improvement and steady-state biologic levels, and the role of repeat imaging in recalcitrant cases.
19:23Biologic Selection and Evidence Base — Review of biologic options for perianal Crohn's disease, with infliximab having the strongest evidence base from the original 1998-1999 New England Journal of Medicine trial showing improved healing and reduced recurrence when combined with seton drainage.
21:52Summary and Closing — Recap of key learning points including risk factors for IBD in perianal disease presentations, multidisciplinary management principles, surgical technique pearls, and postoperative biologic timing.

Key claims

9:17Males over age 10 with perianal fistulas have a much higher incidence of Crohn's disease diagnosis — Jason Friser
9:29In pediatric patients, the first presenting factor for Crohn's disease can often be perianal disease — Jason Friser
9:40Patients often present with perianal disease because that's what really hurts, then deeper history reveals GI symptoms like diarrhea and abdominal pain — Jason Friser
6:52The highest risk factors for lymphoma with biologics are males, teenagers, and combination with methotrexate — Jason Friser
12:31Mucosa heals first, so if you treat with a biologic and heal the mucosa while an abscess persists, you will get a recurrent abscess — Jason Friser
13:12Making a big cruciate incision and packing a perianal abscess with gauze in a patient who may have Crohn's can result in non-healing and may require colostomy or ileostomy — Jason Friser
20:55The initial Remicade paper from 1998 or 1999 in New England Journal of Medicine was on perianal disease and demonstrated improved healing time and improved length of time between recurrence when combination of seton and infliximab is used versus either separately — Jason Friser
20:27Remicade has the most literature on healing perianal disease; Humira is also good but has less literature — Lisa McMahon
20:40Stelara and vedolizumab are sometimes used to treat perianal disease but there is less information; there is even less information on JAK inhibitors — Lisa McMahon
19:12Literature shows about a 10% response rate even without biologics if you put a seton in and take it out, and certainly much better with biologics — Lisa McMahon
17:54Typical seton duration is at least 6 months to allow the inflammatory tract to turn into a non-inflammatory tract — Lisa McMahon
16:59Before starting biologics, you want to get rid of the source of infection and make sure the patient is systemically doing OK — Lisa McMahon
17:26If an abscess is not adequately drained, re-imaging should be done before giving biologics or steroids — Jason Friser
19:23Criteria for seton removal include: bottom looks better, drainage is better, patient is symptom-free, steady state of biologic achieved (loading dose plus at least 3 more doses, typically 2-3 months), and inflammatory markers (fecal calprotectin, ESR, CRP) show systemic disease is under control — Jason Friser
18:45In recurrent cases, re-imaging is obtained before seton removal — Lisa McMahon
3:47When colonoscopy cannot intubate the terminal ileum, options include capsule endoscopy or fecal calprotectin testing — Christine Velasco
4:36If terminal ileum cannot be intubated, the approach is to assume Crohn's disease, treat, and re-scope after a few months of treatment when inflammation has likely gone down — Jason Friser
6:29Infectious complications with biologics include rare risk of tuberculosis, for which quantiferon or PPD testing is done — Christine Velasco
14:13Hydrogen peroxide is preferred over methylene blue for identifying fistula tracts because it is neater — Jason Friser
14:18Technique for hydrogen peroxide injection: use 3% hydrogen peroxide in a syringe with 16-20 gauge angiocath depending on skin lesion size, place speculum in anus to visualize where fistula would be, then inject to identify the tract — Jason Friser

Cases discussed

1:498-year-old male with perianal abscess and terminal ileal Crohn's disease

Points of disagreement

5:12Role of diagnostic laparoscopy when colonoscopy cannot intubate terminal ileum
- Mark Levitt: Recalls Barry Salky recommendation to look at terminal ileum laparoscopically in cases where tissue diagnosis cannot be obtained endoscopically
- Lisa McMahon: Would not do diagnostic laparoscopy on purpose; would need something really significant pushing that way
- Jason Friser: Attributes historical use of laparoscopy to greater fear of Remicade in 1998 when it first came to market; less commonly done now
11:45Whether to make counter-incision for perianal abscess drainage
- Lisa McMahon: Did not make counter-incision because abscess spontaneously drained at dentate line and did not want to leave patient with drain on first encounter
- Jason Friser: Would have made a stab incision with #11 blade, drained it, and placed a seton using large vessel loop, to ensure adequate drainage before starting biologics

Open questions

What is the optimal timing for repeat imaging before seton removal in patients with recurrent perianal disease?
What are the comparative effectiveness and safety profiles of newer biologics (Stelara, vedolizumab, JAK inhibitors) versus infliximab for pediatric perianal Crohn's disease?
What is the role of routine preoperative MRI pelvis versus selective imaging based on clinical findings in pediatric perianal Crohn's presentations?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Perianal Abscess in an Eight-Year-Old: When to Suspect Crohn's Disease

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Case narrative · AI-written, human-reviewed

Presentation

An 8-year-old boy arrived in the emergency department with three days of perianal pain and fever 9:40. The history was more revealing than the chief complaint: nearly a year of diarrhea and abdominal pain, growth deceleration from the 54th to the 17th percentile over four years, and an outside MRE showing terminal ileal inflammation 9:40. Exam revealed multiple skin tags, fissures, and a deep, focally tender perianal mass 9:40. Ultrasound confirmed a complex collection measuring 2.5 × 3.5 × 2.5 cm with hyperemic soft tissue 9:40.

The perianal findings were not incidental. Males over age 10 with perianal fistulas carry a much higher incidence of eventual Crohn's disease diagnosis 9:17, and in pediatric patients, perianal disease can be the first presenting manifestation 9:29. One of the discussants noted that patients often present with perianal complaints because the pain drives them to seek care, while deeper history reveals chronic gastrointestinal symptoms 9:40.

The Decision Point

The team faced a surgical dilemma common in pediatric inflammatory bowel disease: how aggressively to drain the abscess without creating iatrogenic injury that would complicate future management 13:12. The standard adult approach — wide cruciate incision, packing with gauze — carries significant risk in a child who may have Crohn's disease 13:12. One discussant warned that aggressive incision and packing in a patient who may have Crohn's can result in non-healing wounds that may require diversion 13:12.

The concern is not merely technical. Mucosa heals first under biologic therapy; if the mucosa seals while an abscess cavity persists, recurrent infection is nearly guaranteed 12:31. The gastroenterology team would need source control before initiating immunosuppression 16:59, but overly aggressive drainage could leave a non-healing wound that defeats the purpose of medical therapy 13:12.

Management

The patient was started on IV ciprofloxacin and metronidazole and taken to the operating room the following morning 9:40. Exam under anesthesia confirmed multiple skin tags and fissures 9:40. The abscess had spontaneously drained at the dentate line, leaving an opening at least 1 cm wide extending about 1 cm into subcutaneous tissue 9:40. Critically, no counter-incision was made to avoid creating a fistula tract where none existed 9:40.

The discussants emphasized restraint. "I don't like to make holes when there aren't holes there" [q1], referring specifically to the rectal and anal mucosa. The alternative approach: a small stab incision, drainage, and placement of a vessel-loop seton — enough to control infection without committing the patient to a chronic wound 13:12.

Post-operatively, antibiotics were continued 16:59. Before starting biologic therapy, the team needed both source control and tissue diagnosis 16:59. Combined EGD and colonoscopy after bowel preparation showed terminal ileitis with erythema and friability 16:59. Only after confirming adequate drainage and systemic stability was biologic therapy initiated 16:59. If drainage had been inadequate, re-imaging would have been obtained before proceeding with immunosuppression 17:26.

The Seton Strategy

The seton itself became part of the therapeutic plan, not merely a temporizing measure. Typical duration is at least six months, allowing an inflammatory tract to become non-inflammatory 17:54. Criteria for removal are specific: improved appearance of the perineum, reduced drainage, symptom resolution, achievement of steady-state biologic levels (loading dose plus at least three additional doses, typically 2-3 months), and normalization of inflammatory markers including fecal calprotectin, ESR, and CRP 19:23.

The choice of biologic matters. Infliximab has the most literature supporting efficacy in perianal disease; adalimumab is also effective but less extensively studied 20:27. The foundational trial demonstrated that combination therapy with seton and infliximab improved both healing time and time to recurrence compared to either intervention alone 20:55. Even without biologics, seton placement alone achieves a response; biologics substantially improve outcomes 19:12.

What the Case Changes

The transferable judgment is this: in a prepubertal or adolescent male with perianal abscess, especially one with constitutional symptoms or growth failure, think Crohn's disease before making the first incision 9:17 9:29 9:40. Drain conservatively 13:12. Place a seton if there is communication with the anal canal 17:54. Do not pack aggressively 13:12. Obtain tissue diagnosis before starting biologics, but do not delay source control waiting for endoscopy 16:59. The mucosa will heal faster than the perianal wound; plan accordingly 12:31. The outcome of this specific case was not discussed beyond the initiation of therapy.

Takeaways from this story

Males over 10 with perianal fistulas have much higher Crohn's incidence; perianal disease may be the first presentation in children.
Avoid aggressive packing of perianal abscesses in suspected Crohn's; mucosa heals first under biologics, trapping residual infection.
Setons typically remain 6+ months; remove only after biologic steady state, symptom resolution, and normalized inflammatory markers.
Infliximab plus seton improves healing time and recurrence interval versus either alone; combination therapy is evidence-based.

Perianal Crohn's Disease in Children: When the Bottom Brings the Diagnosis

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Exists as a Distinct Problem

Perianal Crohn's disease exists at the intersection of two subspecialties — pediatric surgery and pediatric gastroenterology — because neither can manage it alone. The surgeon drains the abscess but cannot treat the underlying inflammation; the gastroenterologist prescribes the biologic but cannot achieve source control of infection. In pediatric patients, perianal disease can be the first presenting feature of Crohn's, often before any bowel symptoms become apparent 9:29. A child presents with pain severe enough to bring them to the emergency department, and only on deeper questioning do diarrhea and abdominal pain emerge 9:40. Males over age 10 with perianal fistulas carry a much higher incidence of eventual Crohn's diagnosis 9:17, making this a high-stakes clinical scenario where the initial surgical approach can determine whether the child heals or requires fecal diversion.

The Core Clinical Problem

The problem is timing and sequencing. "The thing that's going to heal first is the mucosa" [q2]. If you start a biologic and heal the intestinal lining while an undrained abscess persists, you will get a recurrent abscess 12:31. If you perform an aggressive cruciate incision and pack the wound with gauze — standard practice for a simple perianal abscess — you may create a non-healing wound in a patient with undiagnosed Crohn's that ultimately requires colostomy or ileostomy 13:12. The surgical principle is minimalism: achieve drainage without creating iatrogenic injury, then coordinate with gastroenterology to initiate immunosuppression only after source control is established.

How the Approach Works

Diagnosis. When colonoscopy cannot intubate the terminal ileum to obtain tissue diagnosis, options include capsule endoscopy or fecal calprotectin testing 3:47. If intubation fails, the practical approach is to assume Crohn's disease, initiate treatment, and re-scope after a few months when inflammation has subsided 4:36. Before starting biologics, infectious workup includes quantiferon or PPD testing for tuberculosis 6:29. The highest risk factors for lymphoma with biologic therapy are males, teenagers, and combination with methotrexate 6:52.

Surgical technique. The goal is drainage with seton placement, not wound creation. Use a small stab incision rather than cruciate incision, drain the abscess, and place a vessel loop as a non-cutting seton 13:12. To identify fistula tracts, hydrogen peroxide is preferred over methylene blue: use 3% hydrogen peroxide in a syringe with 16-20 gauge angiocath depending on skin lesion size, place a speculum in the anus to visualize the expected fistula location, then inject to identify the tract 14:18. "The biggest thing is being careful not to make a fistula where there wasn't one" [q4] — gentle probing distinguishes a true tract from iatrogenic mucosal perforation.

Timing of immunosuppression. Before starting biologics, you must achieve source control of infection and ensure the patient is systemically stable 16:59. If abscess drainage adequacy is uncertain, re-imaging is required before giving biologics or steroids 17:26. The patient should be afebrile and systemically well.

Seton management. Typical seton duration is at least 6 months to allow the inflammatory tract to become non-inflammatory 17:54. Criteria for removal include clinical improvement (better appearance, less drainage, symptom-free), steady-state biologic levels (loading dose plus at least 3 additional doses, typically 2-3 months), and controlled systemic disease as measured by fecal calprotectin, ESR, and CRP 19:23. In recalcitrant cases — where a seton was removed, the patient initially did well, then developed recurrent drainage or abscess requiring another seton — obtain repeat imaging before the second removal 18:45.

Biologic selection. Infliximab has the strongest evidence base for perianal Crohn's disease. The original New England Journal of Medicine trial from 1998-1999 was specifically on perianal disease and demonstrated improved healing time and longer time to recurrence when seton drainage and infliximab are combined versus either intervention alone 20:55. Infliximab has the most literature on healing perianal disease; adalimumab is also effective but has less published data 20:27. Ustekinumab and vedolizumab are sometimes used with less supporting evidence, and JAK inhibitors have even less information available 20:40. Even with seton placement alone, literature shows about a 10% response rate; outcomes are substantially better with biologics 19:12.

Where Practice Is Contested

The role of preoperative MRI pelvis is not standardized. Some centers routinely obtain pelvic MRI before operative intervention, particularly in patients with long-standing disease or multiple prior fistulas. Others proceed directly to examination under anesthesia without imaging to avoid treatment delay. The decision depends on clinical complexity and local practice patterns.

When to Involve This Team

Refer any male over age 10 presenting with perianal fistula for gastroenterology evaluation 9:17. Refer any child with perianal abscess plus red flags: skin tags, fissures, chronic diarrhea, or growth curve deceleration. If you are a surgeon managing a perianal abscess in a child and discover intraoperative findings suggestive of Crohn's — skin tags, fissures, spontaneous drainage at the dentate line — place a seton rather than packing the wound and coordinate with gastroenterology before discharge. If you are a gastroenterologist initiating biologics in a patient with known or suspected perianal disease, confirm with surgery that source control has been achieved and consider re-imaging if drainage adequacy is uncertain.

Takeaways from this story

Males over 10 with perianal fistulas carry high Crohn's risk; perianal disease often precedes GI symptoms in children.
Use stab incision with seton, not cruciate incision with packing, to avoid non-healing wounds requiring diversion.
Mucosa heals before fistula tracts; start biologics only after source control to prevent recurrent abscess.
Keep setons at least 6 months; remove only after steady-state biologic levels and normalized inflammatory markers.
Infliximab plus seton has strongest evidence for perianal Crohn's, improving healing time and reducing recurrence.

Seton Placement Without Counter-Incision: Adequate Drainage or Missed Opportunity?

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Clinical Scenario

An 8-year-old male with suspected Crohn's disease presented with a perianal abscess that spontaneously drained at the dentate line during examination under anesthesia. The internal opening measured approximately 1 centimeter at the dentate line, extending roughly 1 centimeter into the subcutaneous tissue 9:40. The surgeon elected not to make a counter-incision through the perianal skin, reasoning that this was the patient's first encounter and wanting to avoid leaving him with an external drain 13:12.

This decision became the focal point of a technical disagreement about adequate source control before initiating biologic therapy.

The Case for Counter-Incision and Immediate Seton Placement

One of the discussants argued for making a stab incision, draining the abscess, and placing a seton using a large vessel loop 13:12. This position rests on two concerns about mucosal healing dynamics and infection control before immunosuppression.

"The thing that's going to heal first is the mucosa" [q2], one discussant explained. If biologic therapy heals the mucosal opening while residual abscess remains, recurrent infection becomes likely 12:31. From this perspective, gastroenterologists would prefer a seton or drain in place when they initiate biologics and deliberately immunocompromise the patient 12:31.

The broader concern extends beyond this single case, distinguishing between aggressive packing that creates non-healing wounds and controlled drainage with seton placement 13:12.

Before starting biologics or steroids, source control must be confirmed — if adequate drainage is uncertain, re-imaging is obtained 17:26. A seton ensures drainage remains patent during the months required to achieve steady-state biologic levels.

The Case for Observation Without Counter-Incision

The other approach prioritized avoiding an external wound on first encounter. The abscess had spontaneously drained through a 1-centimeter opening at the dentate line when pressure was applied during examination 13:12. This internal drainage was deemed sufficient without creating an additional skin opening.

The rationale implicitly weighs the risk of creating a fistula tract where none existed against the risk of inadequate drainage. One discussant articulated this concern: being careful not to make a fistula where there wasn't one, and distinguishing between finding a true tract versus inadvertently poking through into the mucosa 13:12.

Both positions acknowledge the principle that source control precedes immunosuppression — the patient must be systemically stable, with resolved fever and controlled infection, before biologics are initiated 16:59. The disagreement centers on whether spontaneous internal drainage through a 1-centimeter opening constitutes adequate source control, or whether external drainage with seton placement is required.

Where They Agree

Both approaches reject aggressive cruciate incisions with packing, which risk creating non-healing wounds in patients who may have Crohn's disease 13:12. Both recognize that males over age 10 with perianal fistulas carry substantially higher risk of Crohn's diagnosis 9:17, making conservative surgical technique essential.

Both agree that if drainage adequacy is uncertain, re-imaging is obtained before initiating biologics 17:26. Both would use setons when fistula tracts are identified — the disagreement is whether this particular abscess, with its spontaneous internal drainage, required immediate seton placement or could be observed.

Both recognize that combination therapy with seton and infliximab produces superior outcomes compared to either intervention alone, as demonstrated in the original 1998-1999 New England Journal of Medicine paper on perianal Crohn's disease 20:55.

What Would Resolve It

The discussants did not specify what evidence would settle this question. The decision appears to rest on individual assessment of drainage adequacy in real time — the size and patency of the internal opening, the extent of subcutaneous extension, the ease with which the abscess decompressed, and the surgeon's confidence that residual fluid has been evacuated.

Re-imaging before biologic initiation, which both would obtain if drainage adequacy were uncertain 17:26, provides one resolution pathway. If imaging demonstrates residual collection despite the internal opening, seton placement becomes necessary. If imaging confirms complete drainage, observation may be justified.

The question remains whether a 1-centimeter internal opening provides drainage equivalent to a controlled external incision with seton, or whether the mucosal opening will heal prematurely under biologic therapy while residual infection persists.

Takeaways from this story

Mucosal openings heal faster than skin under biologic therapy, risking recurrent abscess if external drainage is inadequate
Aggressive cruciate incisions with packing in potential Crohn's patients can create non-healing wounds requiring diversion
Source control must be confirmed by re-imaging before initiating biologics if drainage adequacy is uncertain
Males over 10 with perianal fistulas have substantially higher Crohn's incidence, demanding conservative surgical technique

Topic overview

A multidisciplinary discussion of perianal Crohn's disease management in pediatric patients, centered on an 8-year-old male presenting with perianal abscess and terminal ileal inflammation. The panel addresses diagnostic challenges when colonoscopy cannot intubate the terminal ileum, surgical decision-making for abscess drainage and seton placement, timing of biologic therapy initiation relative to infection control, and criteria for seton removal. Key clinical points include the high incidence of Crohn's disease in males over 10 presenting with perianal fistulas, the importance of avoiding aggressive incision and drainage that may create non-healing wounds, and the evidence base for combining seton drainage with anti-TNF biologics (particularly infliximab) for perianal fistulizing disease.

Key takeaways

Males >10 with perianal fistulas have high Crohn's incidence; perianal disease may be first presentation in pediatrics. (9:17)
Avoid aggressive I&D in suspected Crohn's perianal abscess—cruciate incisions can create non-healing wounds requiring diversion. (13:12)
Drain abscess before starting biologics; inadequately drained collections require re-imaging before immunosuppression. (16:59)
Seton + infliximab combination superior to either alone for perianal Crohn's; typical seton duration ≥6 months. (17:54)
Remove seton when: perianal exam improved, patient asymptomatic, biologic steady-state achieved, and inflammatory markers controlled. (19:23)

Keywords

Crohn's disease inflammatory bowel disease (IBD) perianal abscess perianal fistula terminal ileitis fissure lymphoma tuberculosis cellulitis colonoscopy EGD (esophagogastroduodenoscopy) MRE (MR enterography) MRI pelvis capsule endoscopy exam under anesthesia

Hashtags

#PerinealCrohns #PediatricIBD #ColorectalSurgery #PediatricGastroenterology

Transcript

Click "Show Transcript" to view the full text (21871 characters)

Hey there listeners. Welcome to another episode of the Colorectal Quiz. I'm Shimon Jacobs, colorectal surgery fellow at Children's National in Washington DC. Today we have a very special episode on perianal Crohn's disease, and we're going to be referring to a few images relevant to the case. If you haven't yet downloaded the Stay Current app, go to the Apple App Store or the Google Play Store. It's the easiest way to follow along with this podcast and also access hundreds of other resources in pediatric surgery. Now let me introduce our first host, Doctor Jason Friser, director of the Colorectal Center at Cincinnati Children's. How are you feeling today? I'm excited today because for 2 reasons, actually 31, we're doing a little bit of a different topic today. We're excited about that. 2, I'm getting to reconnect with some old friends. And 3, my former colorectal fellow is on the line too. So, this is really exciting, a little bit of a reunion of a lot of friends of mine. Uh, without further ado, Mark, you ready? Ready. That's our second host, Doctor Mark Levitt, Chief of the Division of Colorectal and Pelvic Reconstruction at Children's National Hospital. Here today to share his expertise. And now, let's welcome our distinguished guests. First, we have Doctor Lisa McMahon, who is the surgical director of the IBD clinic at Phoenix Children's Hospital, and she has brought with her, her pediatric surgery fellow. Uh, Christine Velasco, who I always had the pleasure of training a few years ago at Cincinnati Children's, and now she's showing off her talents at Phoenix Children's Hospital. OK, let's get into it. Here to kick us off with their interesting case is Doctor Velasco. So today, we're going to be talking about an 8-year-old male who presented to us with 3 days of perianal pain in the emergency room. He had previously been, being worked up for IBD at another hospital due to a history of diarrhea for almost a year, some abdominal pain. And while he was supposed to have his uh colonoscopy and EGD done, he ended up having it canceled and presented to our hospital due to fevers. His perineal exam showed a lump that was deep to the skin and focally tender. The ER had obtained an ultrasound of the perineum, which showed a complex collection, 2.5 by 3.5 by 2.5 centimeters with hyremic soft tissue. Let's Talk a little bit about this. What I'm hearing is an 8-year-old that's already being followed for Crohn's, that's never had any surgery, and now has something wrong in their perineum. Is that, is that correct? Correct, not officially diagnosed with IBD. And, and just out of curiosity, just from a radiology point of view, you, he had an MRE. The outside MRE showed 30 centimeters of inflammation of his terminal ileum. What's the colonoscopy for? For the. Pathological diagnosis. Uh-huh. So what do you, what do you actually do? What do the gastroenterologists do? They're going to take biopsies throughout the colon, terminal ileum, and then an EGD as well. OK. So, I just wanna make sure, I mean, there are a lot of people on this call or listening to this podcasts. The colonoscopy might be normal for the entire colon, right? Even the biopsies might be normal. The duodenum might be normal. And the money might be in a biopsy of the terminal ileum, but what if they can't get into the ileocecal valve? How do you make a diagnosis? You do a capsule study. You can also send fecal uh calprotectin. Uh-huh, OK, good. So, so we need to make the diagnosis. We're, we're seeking a diagnosis here, and then this poor kid comes in with a very significant perianal problem. And by the way, the ultrasound, the ultrasound they did was, was just of the perineum or they did a. Uh, we don't. Routinely, I, uh, really get transrectal ultrasounds. Do you get those? We have to distinguish what the adults, the adults do it all the time. We have actually a, a, a GI doctor who has a scope that has transrectal ultrasound, and we have actually the wand transrectal ultrasound, um, just starting to learn how to use them though and how it works. But anyway, going back to this case, Mark alludes to some great problems, and if you can't intubate the terminal ileum with your Uh, colonoscope, then you really don't have a tissue diagnosis. Then you have to go to the assumption you have Crohn's disease, treat, and then re-scope after a few months of treatment, where it likely inflammation has gone down and you could, uh, intubate the terminal ileum and get tissue for true pathologic diagnosis. But that's a very Stressful situation for our GI colleagues because then they're using medications without the true tissue diagnosis which we always want to have. Jason, would you do a diagnostic, or Lisa, would you do a diagnostic laparoscopy in that case? Jason and I trained, both trained at Mount Sinai, where Doctor Crone was. Um, and so there was a lot of IBD. Um, and I remember, and maybe I'm dating myself a little bit, but the, the Barry Sakey recommendation in that case was to take a look at the terminal ileum laparoscopically. Is that something, not something we would do? Not on purpose. I wouldn't do that on purpose. Um, I think, I think there'd have to be something really huge pushing me that way. Or if it was an accident, going for something. I think back in 1998, Mark, when Remicade first came out in the market, people were a little more fearful of, of, uh, prescribing that as they are now. Are people no longer afraid of Remicade or biologics? I think people are less afraid of them. Although in this case, it actually factors in because these will, you'll hear, the parents are very, very afraid of Remicade, and I think it has to do with how they were counseled initially. This is really important to know for all pediatric surgeons, gastroenterologists, trainees, and everyone taking care of children with IBD. What are some of the real risks associated with biologic agents? So, uh, infectious complications, like, you know, rare risk of getting, you know, tuberculosis. Uh, we usually will send a quantiferon for that or PPD, uh, risk of lymphoma. I think that is one of the ones that tends to scare, in my experience, scare uh families and parents the most. More often, the highest risk factors of males, teenagers, and in combination with methotrexate. So, the, but, Those are just higher risk factors, it, it is a black box label to all patients, and, and that's why there's some hesitancy to get a tissue diagnosis to make sure you're treating the right thing when you're putting a patient at risk with something like this. Lisa, am I right in thinking this is a pretty atypical case that has both TI and perineal disease, basically at the same time. I, I think it's actually pretty common to have perianal disease and Crohn's, and he just has a delay in diagnosis. And then he's actually had perianal disease for quite some time. He's had multiple little skin tags and fissures. No other abscesses that we know of or that he could tell us. But I don't, I don't think this is a really atypical. Thing for him. OK. So let's, let's hear more about the case. So he was initially admitted and started on IV Cipro and Flagyl. Then the next morning, we took him to the operating room for an exam under anesthesia, possible incision and drainage, and possible seatone placement. Here's a very important learning point. How do you know when to take the patient to the OR? Do you have enough information at this point about the abscess to come up with a surgical plan? Um, I went to the OR with an ultrasound that showed a fluid collection and a kid that told me he had an indurated area, um, with the suspicion of him having Crohn's. I did not go to the OR with an MRI. My pelvis, which is what I often do with kids who've had either long-standing disease, maybe multiple fistulas or fissures in the past, something else going on. There, there, there's some literature on this, and, and there are algorithms for this treatment. And so Doctor Velasco and myself have just published a paper on this. The article you're referring to was published in the Journal of Pediatric Surgery in September 2021. What were your key findings? First, a patient that comes to the ER with a perianal lesion. Often in the adult world, the perianal lesion, the resident goes down, does an incision and drainage, and packs it and it goes away. We looked at this, we looked at over 1100 patients that came to our emergency room with either an abscess, a fistula, or a fissure. And found that male over the age of 10, and if they actually have a if you find a fistula. So those three things sort of have a much higher incidence of Crohn's disease being diagnosed. The other thing we found is that in pediatric patients, unlike adult patients, the first presenting factor for Crohn's disease can often be perianal disease. And we started to talk about the combination of perianal and ileal disease, which may be present, but a lot of patients often present with perianal disease cause that's what really hurts the child. Then you get a deeper history and go further back and you're like, oh, they do have some GI symptoms, some diarrhea, some abdominal pain, but that really didn't bring them to the emergency. Are you suggesting, Jason, that those patients who present with a perianal problem. Um, who have a high incidence of potentially finding Crohn's ought to have a more significant workup than just some I&D, or, and what, and what would that be? Great, great. Um, way to segue into what our original question was, is, is, did we need to do more of an imaging workup in this patient? And so, my answer to it, if we are not delaying treatment, The acute treatment is this abscess and this painful perianal lesion. If you can get an MRE or an MRI in the pelvis, so you can make sure there's no hidden or horseshoe fistulas or deeper lesions, and I usually try to coordinate with my GI colleagues to get the scopes done at the same time, limit the anesthesia if possible, then I coordinate. That within a 24 or so hour period and give the kid antibiotics and get the prep done. If that's not possible for many reasons and we all work in busy hospitals, then that, that, that workup might have to be um segmented, treat the perianal disease, and then work up the IBD afterwards, especially if you have a non-healing lesion. Very good, very, very helpful summary. Let's hear about the findings in the operating room. In fact, if you're listening on the state current app, you can pull up the photo of the exam that Doctor Velasquez is going to describe. When we got to the operating room, we saw the multiple skin tags. We were able to see that there were fissures that were not initially noted. On internal exam, there was an actual uh draining, abscess cavity was draining at the dentate line. So we elected to not make a counter incision to try and prevent fistula tract forming with the skin. This abscess, um, as soon as I pushed on his bottom to try to find it, spontaneously drained into his at his anus. And there was an opening at the dentate line that was at least 1 centimeter wide, and I. And it came, um, to the kind of subcutaneous skin, maybe 1 centimeter in. But I didn't feel like I wanted to make a counterincision onto his perianal skin and leave him with a drain, having this been like kind of the first thing that time I've ever seen him. So I, when I go to the OR I typically say, I don't like to make holes when there aren't holes there. I'm typically referring that to the rectum or anus and the mucosal lining, not the skin side, because the thing that's going to heal first is the mucosa. And so I, I, I'd be worried if we're gonna treat this kid with a biologic, and you're gonna heal the mucosa and you still have this abscess, you're going to get a recurrent abscess, and I think my GI colleagues would be much happier with a Seton in place or a drain in place from the infection standpoint of when they give a biologic and immunocompromise the patient. The purpose of the paper I alluded to before was, is that I don't like when we get a kid in the ER, a 10 year old boy. With a perianal abscess, and we go and make a big cruciate incision and pack it with tons of gauze, and, and that thing doesn't heal, you're in trouble. You, you may have bought that kid a colostomy or ileostomy. I would have done a taken a little 1n blade, made a stab, drained it, put a seaton in. I use a a maxi vessel, a large vessel loop as my seaton, and um we don't use cutting seatons anymore, and then continued the workup for inflammatory bowel disease. So when you're in the OR and you're struggling to find one or more openings of the fistula, do you have any tips or tricks? That you can try to help you figure it out. The biggest thing is being careful not to make a fistula where there wasn't one. And, you know, you think, aha, I found one and it's really, you've poked through into the mucosa. Then other things you can use are like hydrogen peroxide, squirting that into the tract or where you think the fistula tract is. I don't use methylene blue. Jason had methylene. I have, but I, I much prefer hydrogen peroxide. It's neater. I, the trick for me is I, I get 3% hydrogen peroxide, put it in a syringe, attach like a 20 gauge or so, 16 gauge angiocah depending on the size of the skin lesion. Uh, I usually put a speculum in the anus so I could see inside the anus, approximating where I think the fistula would be located, and then I inject the hydrogen peroxide to try to lead me towards the fistula. I feel more comfortable telling the families when I go in and I don't come out with the san that I did all these things, and the mucosa probably healed, and hopefully it'll heal from the inside out. And again, like Christine alluded to, I do not like poking holes where there isn't a hole, so I use a, a uh Probe, gently pass it through. It has a, a fish eye on the end so that I could pass aceton through if I need to. And um if I don't find a hole and I do my hydrogen peroxide uh test and it's negative, then I don't put aceton in at that time. Let's continue on to the post-op hospital course. After we finished in the operating room, we continued the antibiotics and gastroenterology saw the patient, and he underwent a bowel prep and EGD and colonoscopy. If you're in the state current app, look at the next images to visualize the findings being described. In the terminal ileum, there was significant erythema and friability indicative of terminal ileitis. What are, what are your take home points? What, what do you want our audience to know? So I think in addition to the peri, just the perianal abscess, he had these, you know, skin tags that were worrisome from the get-go, even if he had not already been being. Worked up. And then in the exam in the operating room, seeing the skin tags, the fissures, and then this, uh, abscess collection, I think was worrisome. And then, you know, upon further talking with the patient, he's had diarrhea for a year. And actually, over a 4-year period, he had actually gone from the fifty-fourth percentile. Down to the 17th percentile, definitely had fallen off of his growth curve, which was more worrisome than just a simple uh a perianal abscess that could be IND'd and sent home. OK, so you go to the OR, you drain the abscess, that's an infection. There might be associated cellulitis. Do you have a protocol of when do you start immunosuppressing the patient with steroids and a Biologic. Um, we don't have a protocol, but it's a very good point. You definitely want to get rid of the source of the infection prior and like, make sure systemically he's doing OK. Cause remember, he came in with fevers. So he was started on antibiotics. He didn't start any sort of systemic therapy until this kind of process resolved. And, for us, when we have a patient with an abscess and we're not sure if it's adequately drained, we would reimage before. Giving the biologics, or what about the steroids? The steroids probably as well, um, we would re-image, so if your abscesses or your infection is not source controlled, we would wait and make sure that is under control before giving a um immunosuppressant. What I wanna ask you guys is, maybe this patient develops another abscess, you have to put a seaton in, it has a Seton. When do you take it out? I counsel all of my patients that get Setons that they're probably gonna have it for at least 6 months. I think it takes a while for that, um, inflammatory tract to turn into a non-inflammatory tract, and it's sort of a negotiation in a sense. So I'd like to bring them back to clinic and see what they look like on a pretty regular interval to make sure things are OK. Certainly, I've had kids who've had Setons and then get abscesses other places. too, and then that, that puts them down the line of getting another MRI and trying to figure out what's going on and making sure their biologics are working. But if it's just a straight up single Cton, uh, that their other symptoms are getting better, their bottom looks good on my clinical exam in the office. OK, I take the Seton out. They continue on their biologic, and I don't see them again for bottom problem. Not everybody do I get re-imaging on. Before I take the Seton out, it's the kids that have been recalcitrant. So I've taken the seaton out after 6 months, they've been doing well. All of their numbers look good. Their fetal coprotectin is like more in the normal range. They look, they're eating well, they're healthy, their bottoms look good. I take it out, and then they start draining again, or end up with an abscess in the area that needs another ceton. Before I take that one out, I'm definitely gonna image those kids. So. I think the literature shows about a 10% response rate even without biologics, if you put a keton in and take it out, and then, um, certainly much better with biologics, so. I have a few rules that the bottom has to look better, the drainage has to be better, the pain, the symptoms have, you have to be symptom free. I make sure that they get a steady state of biologic in them, which usually means a loading dose and at least 3 more doses of medication, which usually takes you somewhere between 2 and 3 months from start of treatment. So I typically leave my seatons in for at least that period of time. On the recurrent patients, I'm much more Uh, hesitant to take it out and much more, um, cautious. I also check inflammatory markers before pulling it out, making sure the systemic disease is under control. So I look at fecal calprotectin, ESR sed rate, uh, CRP. With regard to the biologics, in, in this case, and similar cases, What exactly are you treating? Are you treating the perianal problem? Are you treating the terminal ileum? Are you treating both? And does the biologic choice or dosing matter? I think Remicade is the one that um has the most kind of literature on in terms of healing period. Anal disease, you know, and anti-TNF is, and like Humira also good. It has less literature. Um, the Stelara and like the veallizumab sometimes are used to try to treat it. Um, there's less information on Teds. And it allows for one minute of history and the New England Journal paper written, I believe it was either. 1998 or 1999, the initial Remicade paper was on perianal disease and demonstrated improved healing time, improved length of time between recurrence, um, when a combination of stan and infliximab is used versus either separately. Uh, so, our initial papers came out for perianal fistulizing diseases. Now, two decades later, it's been shown to have a tremendous amount of effects on stricturing disease and um on ileal disease. And other intestinal manifestations. I think our dosing is more, more known now. The um issue with antibodies to the biologics is known and, and being able to get levels and testing that um are all important. That wraps up our case this week we reviewed perianal Crohn's disease and a case of a patient presenting to the ED with an abscess. We discussed that males, teenagers, and patients with a fistula exam have a higher risk of an underlying IBD diagnosis and how to work them up preoperatively with lab work and imaging. We highlighted that IBD is a multidisciplinary disease and close work between the surgeon and the gastroenterologist, especially for procedures, is best for patients. We shared strategies in the OR for IND and CTO placement, then discussed the post-op management with how to follow up patients in clinic, who needs repeat imaging, and when to start biologics, as well as some other associated risks. And now, the moment you've been waiting for, our joke of the week. First, I'd like to thank our guests, Lisa and Christine for joining us as it was a pleasure to catch up with you guys and hear your case and your thoughts on perianal Crohn's disease. And we, I talked a little bit about the dinosaur ages. What dinosaur had the best vocabulary? This one's terrible, really like maybe hits the bottom of the bottom of the barrel. The thesaurus, uh, by the way, uh, that's very good, but I will tell you in follow up to that, what's the, what's the name of that dinosaur, the, the, the flying, um, the flying one, the bird, like pterodactyl, yes, you never know, you can never know when they go to the bathroom. You never know. You know why you don't know? Yeah, the pee is silent. That's phenomenal. What I love how we put it all together, man, this is just as bad as it gets. I'm, if you're still listening, thank you, but God bless you because wow. Thank you for tuning in to this week's episode of the Colorectal quiz. I welcome you to browse our previous podcast on the Stay Current app. Till next time, I'm Shimon Jacobs from Children's National. It's been a pleasure learning together with you because knowledge should be free.

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