Crohn’s disease can affect the digestive tract, all the way from the mouth to the anus. It is understandable that most people with Crohn’s do not wish to speak about one of the most common and painful symptoms associated with Crohn’s disease: anal fistulas. Most avoid the subject because they find it to be embarrassing, but it is a subject that is important to discuss in order to raise both knowledge and awareness.
Around 60% of people with Crohn’s disease will likely develop an anal fistula at some point in their lives. This is because the inflammation that arises within the body as a result of Crohn’s disease often penetrates through the bowel wall. In turn, it triggers the formation of leaks, ulcers, and abscesses. Around 50% of abscesses, which are infected cavities, may develop into a fistula.
What exactly is a fistula?
A fistula is a small tunnel that connects either the bowel to the other organs (such as the vagina, bladder or skin) or it connects together two different parts of the bowel. Fistulas that are smaller may not trigger any symptoms, but ones that are larger may become infected and lead to symptoms such as bleeding, painful discharge of pus or blood when passing stools, swelling or irritation near the anus, fever, and night sweats.
There are several different types of fistulas, including:
- Enterovaginal fistula – A fistula that connects the bowel to the vagina
- Enterovesical fistula – A fistula that connects the bowel to the bladder
- Enterocutaneous fistula – A fistula that connects the bowel to the skin
- Enteroenteric fistula – A fistula that connects together different parts of the bowel or intestine
By far, the most common type of fistula is the anal fistula. An anal fistula is a small tunnel that connects the end of the bowel to the surface of the skin near the anus. In some instances, an anal fistula may trigger persistent drainage or even recurrent anal abscesses, for which the only cure is surgery.
Avoiding embarrassment and finding relief
Brian Greenberg, founder of the Intense Intestines Foundation, was diagnosed with Crohn’s disease at the age of 11. Living with Crohn’s, he experienced several abscesses and fistulas due to his disease. However, his freshman year of college was a period in his life when he tried to ignore his first abscess. He experienced all of the symptoms but he was not quite aware of what was really going on inside his body. “That is, until one day the fistula decided to pop in the middle of class and an enormous amount of infectious material flooded my pants,” he said. For Brian, as well as a majority of individuals dealing with anal fistulas, one of the most difficult symptoms is pain.
While there are a few approaches that can provide temporarily relief, including warm baths and specific creams, some of the most common treatments for fistulas include medical treatment, such as antibiotics and immunosuppressants, surgical treatment, and non-surgical treatment, such as fibrin glue. “Some older research shows that antibiotics are helpful,” said Adam Ehrlich, assistant professor of medicine at the Lewis Katz School of Medicine. Yet, recent data supports the use of TNF-alpha drugs to suppress inflammatory responses. “Anti TNF-alpha drugs have become the standard of care for the medical treatment of fistulas in Crohn’s disease patients,” he added.
Treatment generally depends on the type of fistula in question, its position, as well as the treatment already in place for one’s IBD. The objective of the surgery is to heal the fistula by avoiding damage to the surrounding muscles that are responsible for opening and closing the anus. A more specific overview of the different types of surgeries for anal fistulas include the following:
- Fistulotomy – A common surgical procedure used to treat simple low anal fistulas (accounting for over 90% of cases). The rectal and colon surgeon opens the infected fistula, removes the contents within it, and flattens it out. After around 4-8 weeks, the fistula should heal into a flattened scar.
- Fistulectomy – A surgical procedure that involves complete removal of the anal fistula.
- Seton stitch surgery – A surgical procedure used to treat complex or high anal fistulas. The rectal and colon surgeon inserts a plastic surgical thread through the fistula and back out through the anus. It keeps the fistula open for several months, helping to drain away the pus and giving the fistula a chance to properly heal on its own.
- Advancement flap procedure – A surgical procedure used to treat complex or high anal fistulas. A rectal and colon surgeon removes an advancement flap, which is a piece of tissue extracted from the rectum or the skin surrounding the anus. He or she then removes the fistula and the advancement flap is attached at the opening where the fistula was originally present.
- Bioprosthetic plug – A surgical procedure that involves the use of a cone-like plug made from human tissue to block the opening of the fistula. The rectal and colon surgeon also uses stitches to keep the plug in position. However, it does not entirely close off the fistula, thereby allowing it drain, heal, and form new tissue around the plug.
Only one non-surgical option
If there is not active infection and the fistula can be maintained under control, a rectal and colon surgeon may recommend fibrin glue. The fibrin glue is inserted into the fistula through its opening and afterwards, the opening is stitched shut. To date, fibrin glue is the only non-surgical treatment option available for anal fistulas. Although it is considered a safe and pain-free procedure, the overall success rate of fibrin glue is rather poor.
What about stem cell therapy?
A review published last year showed the potential of stem cell therapy being a promising treatment option for fistulas in the near future. Stem cell therapy involves taking stem cells from a patient’s fat tissue and using them to form a tissue plug to be placed in the fistula, thus allowing it to heal properly. Although stem cell therapy is still in the experimental stages of research, it could prove to be effective in controlling Crohn’s disease by presenting fewer side effects. “In the future, our hope is to find a way to prevent or cure Crohn’s disease, but in the meantime, we keep working hard to make life as good as possible for our patients,” said Ehrlich.
When it comes to Crohn’s disease, the subject of anal fistulas is often one that no one talks about. However, it extends farther beyond the urgent need to use a restroom. Fistulas are one of the most common complications of Crohn’s and they can result in severe bleeding, infections, and loss of control over bowel movements. What’s more, they often affect not only physical health, but mental health as well - leaving an individual to feel uncomfortable and insecure. Therefore, in discussing Crohn’s disease, it is necessary to address all aspects of the disease, including the physical and mental impact of anal fistulas.
As in Greenberg’s case, he stresses the importance of listening to one’s body and dealing with the issue ahead of time. “It makes us more aware and more able to deal with problems when they crop up,” he said. Doing so can help to raise awareness and understanding, as well as to prevent complications further down the road. Anal fistulas are very real and they should not be ignored.