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Complex Perianal Crohn — RACP Adult Medicine MCQ

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ModerateGastroenterologyComplex Perianal CrohnRACP Adult Medicine

A 35-year-old woman with perianal Crohn disease has a complex fistula-in-ano with a draining seton in place. She is on infliximab with adequate trough levels (8 μg/mL). MRI pelvis shows persistent active fistula track enhancement despite 6 months of therapy. She has ongoing purulent discharge. What additional treatment should be considered?

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Correct answer: A — Exam under anaesthesia with seton adjustment + continue infliximab + consider adding ciprofloxacin/metronidazole

Complex perianal Crohn fistulae require multidisciplinary management (gastroenterologist + colorectal surgeon). Optimal approach: combined medical (anti-TNF — infliximab preferred) + surgical (EUA with seton placement for drainage, advancement flap/LIFT procedure for definitive closure once inflammation controlled). Antibiotics (ciprofloxacin + metronidazole for 4-8 weeks) are commonly used adjunctively. MRI pelvis is the gold standard for assessing fistula healing. Biological healing (MRI) lags behind clinical healing by months.

Reference: GESA – 2024 – Perianal Crohn; ECCO 2024; AGA 2024