Fistulas are common in Crohn's disease and occur in the perianal region or are internal, between intestinal structures or between the intestine and other organs such as the bladder or the abdominal wall. This article, published in the journal "Digestion", presents treatments and their outcome.

Medical therapy is the main option for perianal fistulas once abscesses, if present, have been drained. Antibiotics such as metronidazole and ciprofloxacin are efficacious treatments, though they do not introduce complete healing. Withdrawal of these agents tends to lead to re-exacerbation of the disease. Immunomodulators such as azathioprine and 6-mercaptopurine, or methotrexate should be given early in the disease. They are an effective agent both in closing and in maintaining closure of fistulas, though the onset of response can be delayed. In case of resistance to immunomodulators, infliximab, a chimeric monoclonal antibody, should be given. Cyclosoporin A can be used as a treatment in the acute phase, but patients should receive concomitant immunomodulators (azathioprine or 6-mercaptopurine) for maintenance treatment. Internal fistulas are usually associated with a more aggressive disease and often require surgery, such as fistulotomy or proctectomy.

The cumulative risk for fistulas in patients with Crohn's disease is 33% after 10 years and 50% after 20 years. Perianal fistulas are the most common (54%). The management of fistulizing Crohn's disease necessitates a close collaboration between gastroenterologists and surgeons.

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