Table 4.

Summary of Consensus Recommendations for the Management of Perianal Fistulizing Crohn’s Disease*

1: In patients with Crohn’s disease and signs and/or symptoms of active fistulizing disease, we recommend imaging (EUS or MRI, based on availability and local expertise) be obtained to delineate the anatomy of the fistula tract(s). GRADE: Strong recommendation, very low-quality evidence.

2: In patients with Crohn’s disease and evidence of complicated fistulizing disease, we suggest surgical consultation. GRADE: Conditional recommendation, very low-quality evidence.

3: In patients with Crohn’s disease and evidence of fistulizing disease, we suggest the use of antibiotic therapy for initial management to achieve symptomatic response. GRADE: Conditional recommendation, very low-quality evidence

4: In patients with Crohn’s disease and evidence of fistulizing disease, we recommend the use of anti-TNF therapy, to induce symptomatic response. GRADE: Strong recommendation, very low-quality evidence.

5: In patients with Crohn’s disease and evidence of fistulizing disease who have achieved symptomatic response on anti-TNF therapy, we suggest the use of continued therapy, to achieve and maintain complete remission. GRADE: Conditional recommendation, low-quality evidence.

6: In patients with Crohn’s disease and evidence of fistulizing disease, when starting anti-TNF therapy, we suggest it be combined with a thiopurine or methotrexate over monotherapy to optimize pharmacokinetic parameters. GRADE: Conditional recommendation, low-quality evidence for infliximab, very low-quality evidence for adalimumab.

7: In patients with Crohn’s disease and evidence of fistulizing disease, we suggest referral for surgical management when there has been an inadequate symptomatic response to medical management strategies. GRADE: Conditional recommendation, very low-quality evidence.

EUS, endoscopic ultrasound; MRI, magnetic resonance imaging; TNF, tumor necrosis factor; *The strength of each recommendation was assigned by the consensus group, per the GRADE system, as strong (“we recommend . . .”) or conditional (“we suggest . . .”). A recommendation could be classified as strong despite low quality evidence to support it or conditional despite the existence of high quality evidence due to the 4 components considered in each recommendation (risk:benefit balance, patients’ values and preferences, cost and resource allocation, and quality of evidence).