An overview of a presentation by Associate Professor Gert van Assche from Leuven University Hospital, Belgium, at the Raising Expectations in Gastroenterology symposium, 2010.

Rectovaginal fistulae are a devastating complication of inflammatory bowel disease (IBD). Active rectal disease is associated with high and complex fistulae and poor surgical outcome, so the underlying disease must be treated effectively.

Comprehensive assessment is an essential first step to effective therapy. This includes:

  • examination under anaesthesia
  • MRI and/or endoscopic ultrasound
  • Assessment of the entire colon

Treatment always requires a combination of surgery and medicine, and a long-term treatment plan is required.

Medical interventions

Active Crohn's disease, especially with rectal inflammation, should be treated medically prior to surgery.

The efficacy of infliximab therapy in patients with Crohn’s disease and one or more draining fistulae was demonstrated by the ACCENT II study. A greater proportion of patients receiving infliximab achieved closure of rectovaginal fistulae eight weeks after completing three infusions vs placebo (44.8% vs 25.1%, p value not provided). The median duration of fistula closure was longer with infliximab vs placebo.1

Prior anti-TNF therapy may not reduce the primary healing rate after surgery, so infliximab can be used to treat proctitis before the surgical intervention.2

Surgical interventions

Patients with symptomatic fistulae usually require surgery, including a diverting ostomy.3 In routine practice, 30–50% of patients can expect fistulae to heal after the first surgical intervention, with additional patients benefiting from subsequent procedures.

Rectal advancement flaps are one surgical approach to rectovaginal fistula. This approach is indicated where there is a single high fistula tract and an absence of proctitis and anorectal stricture.

Fibrin glue has been studied for the treatment of anal fistulae. While this approach may be useful in treating long, tortuous, small fistula tracts with no chronic cavities, no acute sepsis and no side-branches, it does not have a role in treating rectovaginal fistulae.

Summary

  • Comprehensive assessment is an essential first step to effective therapy
  • Active Crohn’s disease should be treated medically prior to surgery
  • Patients with symptomatic fistulae usually require surgery

Please note, the views expressed in this article are not necessarily those of the sponsor.

References

  1. Sands BE et al. Long-term treatment of rectovaginal fistulas in Crohn's disease: response to infliximab in the ACCENT II Study. Clinical Gastroenterology and Hepatology 2004; 2: 912–920.
  2. Ruffolo C et al. Outcome of surgery for rectovaginal fistula due to Crohn's disease. British Journal of Surgery 2009; 96: 1190–1195.
  3. van Assche G et al. The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations. Journal of Crohn’s & Colitis 2010; 4: 63–101.

REMICADE® (infliximab) PBS INFORMATION. Crohn's disease: This is listed as a Section 100 item.

Acute Severe Ulcerative Colitis: This is listed as a Section 100 item [Public Hospital Authority Required (Streamlined); Private Hospital Authority Required]. Please refer to PBS Schedule for full authority information.

Chronic Refractory Ulcerative Colitis: Not listed on the PBS.

Please refer to Product Information before prescribing. Full product Information is available here. Further information is available on request from Janssen-Cilag.

®Registered Trademark of Janssen-Cilag Pty Ltd. ABN 47 000 129 975. 1–5 Khartoum Road, Macquarie Park NSW 2113. Tel: 1800 226 334. AU-REM0178. McCann Health REM0165. Date prepared: April 2014.

PBS information: This product is listed as a Section 100 item for Crohn’s disease and ulcerative colitis. Refer to PBS Schedule for full authority information.

Please refer to Product Information before prescribing. Full product Information is available here. Further information is available on request from Janssen-Cilag.

®Registered Trademark of Janssen-Cilag Pty Ltd. ABN 47 000 129 975. 1–5 Khartoum Road, Macquarie Park NSW 2113. Tel: 1800 226 334. AU-REM0178. McCann Health REM0165. Date prepared: April 2014. Updated: September 2015.