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220 B. Roche, J. Robert-Yap
Crohn’s Disease Fissure
If a midline fissure appears abnormal or fails to heal
with conventional therapy, Crohn’s disease should be
suspected [26]. Spontaneous healing is observed in
80% of patients with Crohn’s fissures followed for
10 years [12]. For this reason, the majority of the fis-
sures may be treated medically. The Lahey Clinic
found that only 15% of 56 patients with fissures
required surgical treatment, despite 88% presenting
with symptoms [27]. A painful fissure is generally
associated with an underlying abscess and may
require an examination of the patient under general
anaesthesia. If an abscess is found, simple drainage
as described in the previous paragraph can provide
relief without incontinence [25]. If no abscess is
found, medical management is appropriate, using
local agents such as topical glyceryl nitrate or isosor-
bide dinitrate, nifedipine or symptomatic measures
such as topical steroids or anaesthetic creams. In
cases of persistent pain, the fissure may be treated as
a classical anal fissure with careful internal sphinc-
terotomy which may provide relief. The Ferguson
Clinic reported healing without incontinence in 22 of
25 patients treated for anal fissure by internal sphinc-
terotomy with a rectum free of disease and an anal
fissure as presentation [28]. In the Lahey Clinic expe-
rience, internal sphincterotomy was successful in
87% of patients without proximal disease, compared
to a 42% healing rate if the proximal intestine was
involved [27].Anal dilatation has not been successful
and is discouraged as therapy. Some Crohn’s ulcers
may be large and acute with erosion into the sphinc-
ters compromising the continence. Intralesional
injection of steroids may be effective if the ulcer is
not too extensive. The natural evolution of these fis-
sures and ulcerations result in strictures of the anal
canal. Unfortunately, many of these patients will
eventually require a proctectomy.
Anorectal Stricture
Chronic anorectal abscesses, fistulae, ulcers or
inflammation may lead to an anorectal stricture.
Three varieties have been described:
1. Short, annular strictures less than 2 cm in length,
resulting in diaphragmatic deformity.
2. Longer, tubular strictures.
3. Strictures secondary to “dysfunction” atrophy.
In a series of 44 patients, Linares et al. [29] report-
ed approximately 50% of the strictures as being
located in the rectum, 33% in the anus, and the
remainder in the anorectum. They also found that
most of these patients had coexisting proctitis or
perianal disease. The majority of strictures are
asymptomatic or well tolerated. If they become
symptomatic, they may be incapacitating because of
urgency, incontinence, tenesmus and difficulty with
defecation. Mild disease may respond to medical
treatment such as topical steroids, 5-aminosalicylic
Fig. 3. Abscess in perineal Crohn’s disease
Fig. 4. Ulceration located at 1 o’clock lithotomy position
with granulation tissue
Surgical Treatment of Perineal Crohn’s Disease 221
acid or systemic metronidazole. Non-invasive surgi-
cal management using gentle dilatation may be suc-
cessful, particularly in cases of short diaphragmatic
lesions. Repeat dilatations may be necessary until
disease remission. Most symptomatic strictures are
not cured with simple dilatation and may require fae-
cal diversion or proctectomy [29, 30].
Anal Skin Tags and Haemorrhoids
Anal skin tags are typically asymptomatic and pres-
ent problems only when they interfere with perianal
hygiene (Fig. 5). They are more prominent with
active intestinal disease. Approximately 25% resolve
spontaneously, generally after remission of concomi-
tant bowel disease. These tags should not be removed
because that may result in an unhealed wound, a
chronic ulcer or perianal sepsis [22]. Exceptions to
this are in cases of severe haemorrhage or suspected
malignancy.
Haemorrhoids are uncommon in patients with
Crohn’s disease. They usually become symptomatic
when accompanied by diarrhoea. Conservative treat-
ment must include control of bowel function, warm
sitz-baths, and topical medications. Usually these
non-invasive measures are successful. If symptoms
persist, rubber-band ligation might be helpful. In
rare cases, if symptoms are severe, and the rectum is
spared from illness, selective surgical haemor-
rhoidectomy may be successful [28].
Most surgeons believe that surgery should be
avoided in the treatment of haemorrhoid diseases in
Crohn’s patients. In a publication, Jeffery et al [31]
reported the results of 21 patients with Crohn’s dis-
ease presenting with active haemorrhoids that were
treated surgically. Postsurgical complications,
including sepsis, strictures, fistulae and unhealed
wounds, occurred in ten patients, and six patients
ultimately required a proctectomy.
Incontinence
Faecal incontinence in patients with perianal Crohn’s
disease is common, occurring in 39% of patients [32].
Management of this condition is challenging because
the cause is often multifactorial. The incontinence
may be secondary to severe perineal Crohn’s disease
associated with chronic fibrosis and scarring of the
anorectum resulting in loss of reservoir function. In
this situation, faecal diversion or proctectomy is
indicated. If the patient suffers from severe Crohn’s-
related muscle destruction, a colostomy is indicated.
Diarrhoea from colonic disease or short-bowel syn-
drome also may lead to incontinence and may
require a colostomy if diarrhoea and stool consisten-
cy cannot be controlled.
On the other hand, incontinence may be unrelated
to Crohn’s disease and may be caused by obstetric
Fig. 5. Anal tags with ulceration and tissue inflammation
Table 1. Stoma and proctectomy rate in Crohn’s disease
Reference No. of patients No. of operations Stoma rate Proctectomy
Shivananda et al. 210 118 (56%) 15 (7%) 18 (15%)
(1989) [44]
Harper and Fazio 139 65 (47%) 44 (32%)
(1987) [45]
Allan and Keighley 171 171 -61 (36%) 20 (12%)
(1988) [46]
Galandiuk et al 356 344 65 (47%) 44 (32%)
(2005) [42]
222 B. Roche, J. Robert-Yap
injury or an overly aggressive surgery such as fistulo-
tomy. The cause may become evident based on med-
ical history and physical examination. Complemen-
tary examinations such as anal manometry, elec-
tromyography, and transrectal ultrasonography will
help in the choice of treatment. Some of these
patients may benefit from sphincter repair when the
Crohn’s disease is in remission. Scott et al. [33] suc-
cessfully treated five of six patients with this type of
surgery. Keighley and Williams [34] reported a 100%
success rate in eight patients who underwent sphinc-
ter repair. In all of these patients, a proximal cover-
ing stoma was used.
Anorectal Cancer
The risk for squamous-cell carcinoma of the anus is
not increased in patients with perianal Crohn’s dis-
ease [15, 35]. The presence of inflammation may
delay the diagnosis of cancer, so in any patients with
persistent perineal ulcers or fissures that fail to heal,
a biopsy of the lesion should be considered. An asso-
ciation exists between colorectal cancer and Crohn’s
disease. [36]. A long duration of illness and the pres-
ence of chronic perianal disease may increase the risk
for rectal malignancy [15, 37–39]. The risk for col-
orectal cancer is not confined just to areas of inflam-
mation; in addition the risk for rectal cancer may be
increased if the rectum has been excluded from intes-
tinal flow or placed out of intestinal continuity. This
is similar to the increased cancer risk in bypassed
segments of small bowel [38, 40]. Lavery and Jagel-
man [41] identified two cases of cancer that devel-
oped in the out-of-circuit rectum after subtotal colec-
tomy and colostomy for Crohn’s disease. Because of
this risk, such patients require cancer surveillance or
proctectomy.
Role for Proctectomy
Devastating perianal complications such as severe
recurrent abscesses and fistulae, incontinence and
anal stenosis, may lead to proctectomy if local proce-
dures are unsuccessful. Fortunately, less than 20% of
patients with a history of anorectal Crohn’s disease
require permanent diversion and/or proctectomy [5,
42]. It is important to consider that the timing of
proctectomy must be dictated by the patient. It is at
this point when they believe that all other medical
and surgical interventions have been exhausted.
Patients need to be psychologically prepared because
this surgical procedure creates a permanent and
definitive stoma. Proctectomy is the last surgical pro-
cedure for perianal Crohn’s disease and gives
patients the best chance for success. It may be cura-
tive in 5% of patients with Crohn’s disease localised
to this region [43].
Anal Fistulae
M.L. Corman observed that, “More surgeons’ reputa-
tions have been impugned because of problems with
fistula operations than from any other operative pro-
cedure” [47]. In general, anal fistulae present symp-
tomatically (Fig. 6). In Crohn’s disease, they have the
reputation of being difficult to treat with a high rate
of recurrence.
Patients are more concerned with postoperative
incontinence, even if minor. Many authors advise the
most cautious attitude in regards to surgical treat-
ment [12, 18, 22, 47]. Many of these assertions are
rooted in the surgical practices of the fifties and six-
ties and have been accepted without much challenge,
particularly in the Anglo-Saxon literature. Anal dis-
ease should not be considered simply as a complica-
tion of intestinal Crohn’s disease. It should be con-
sidered, in the same way as terminal ileal and colonic
Crohn’s disease, as a localisation of the disease to an
anatomical site within the gastrointestinal tract. Tak-
ing this into account, diverse surgical treatment
options can be proposed for the management of anal
fistulae in Crohn’s disease.
Fig. 6. Complex fistulae in Crohn’s disease
Surgical Treatment of Perineal Crohn’s Disease 223
In the presence of active rectal Crohn’s disease,
proctitis may complicate the clinical situation and
lower the rate of healing. On the other hand, patients
with simple fistulae may experience higher rates of
improvement and/or healing compared to a complex
fistulising disease [48]. Fistulae decrease the quality
of life, increase the likelihood of total colectomy and
frequently require surgery [49]. Surgery may consist
of:
1. Fistulotomy: laying open the fistula tract through
a 1 or 2-stage procedure (in case of low fistulae).
2. Non-cutting setons: used in high fistulae involving
a significant portion of the external anal sphincter
(Fig. 7).
3. Endorectal advancement flap: as an alternative to
fistulotomy in patients with low fistulae or an
alternative to non-cutting setons in patients with
high fistulae who do not have macroscopic evi-
dence of rectal inflammation.
Sanitising the Perineum
Abscesses must be drained and necrotic tissues
excised. Any granulation tissue should be curetted,
and sinuses must be deroofed. Simple fistulae should
be laid open, more complex fistulae should be
drained and the primary track marked by a loose
seton. The intention is to end up with a healthy sur-
gical wound from which to use as a starting point.
Medical treatments are discussed in a previous chap-
ter and are always considered as the first choice in
perineal Crohn’s disease treatment. In cases of failure
or recurrence, new procedures such as local injection
of antibody tumour necrotising factor (TNF) or glue
sealing treatment are the second option in fistulae
treatment. Finally, if none of these therapies are suc-
cessful, then quite complicated surgical procedures
can be attempted with a reasonable chance of heal-
ing. All these procedures and the results will be dis-
cussed; the sequence is summarised in an algorithm
for treatment of perineal Crohn’s disease.
Local Injection of Antibody Tumour Necrotising Factor (TNF)
The TNF blocker infliximab has been proven to be
safe and effective in the treatment of both luminal
and fistulising Crohn’s disease, particularly when
used as maintenance therapy with infusions at fixed
intervals [50, 51]. This treatment is described in the
medical treatment chapter. Further advantages of
infliximab therapy include the steroid-sparing effect,
the decrease in concomitant anti-inflammatory med-
ication use (mesalazine, sulfadiazine), as well as the
reduction in hospitalisations and surgeries and the
improved quality of life. Some recent pilot studies
have reported the potential benefit of local injection
of infliximab for the treatment of perianal fistulae in
Crohn’s disease [52–54]. It seems that this method of
administration minimises the adverse effects associ-
ated with the systemic use of infliximab [55].
The treatment consists of a three-step procedure:
1. Removal of the seton.
2. Injection of anaesthetic (5 ml of lidocaine 1%
mixed with 3 ml of 8.4% bicarbonate solution).
3. Injection of infliximab (20 mg diluted in 10 ml of
physiologic solution) along the fistula tract and
around both orifices.
These injections are repeated every 4 weeks until
complete remission is reached and maintained.
Lichtiger reported nine patients with mild to moder-
ate perianal disease refractory to antibiotics, 6-mer-
captopurine or systemic infliximab. They were sub-
sequently treated with circumferential and intrafistu-
lae injections of infliximab at 1, 2 and 4 weeks. With-
in 4 weeks, complete healing of fistulae was observed
in 4/9 patients and a partial response in 3/9 patients,
whereas no response was observed in the remaining
2 patients [53]. Poggioli et al. [54] modified the tech-
nique by injecting infliximab at the internal and
external orifices and along the fistula tract in order to
allow the closure of the entire tract. Fifteen patients
in whom sepsis was not manageable using surgical or
medical therapy, were included in the study. Efficacy
was obtained in ten of fifteen patients after 3 to 12
injections and no major adverse effects were report-
ed. Local infliximab injection seems to be effective,
safe and feasible for the treatment of selected cases of
perianal Crohn’s disease. This treatment can thus
represent an alternative to either medical or surgical
therapies.
Fig. 7. Crohn’s disease fistulae with multiple seton drainage
224 B. Roche, J. Robert-Yap
Glue Sealing Treatment
More recently, fibrin glue injection has also been
proposed as an alternative to classical methods of
surgical treatment for obtaining long-term healing
of Crohn’s anal fistulae [56]. The use of fibrin glues
in the treatment of fistulae-in-ano has been
described over the last 12 years. The results pub-
lished on this subject report success rates of up to
85% (Table 2) [57, 63]. The series studied in the lit-
erature so far have included only a very small num-
ber of patients suffering from inflammatory diseases
where this type of treatment gives rather poor suc-
cess rates [58, 60–63]. Several authors have therefore
concluded that the existence of a fistula complicat-
ing CD is a predictive factor for failure of fibrin glue
injection treatment. Vitton et al. included only CD
patients with anoperineal fistula tracts in an original
study [56]. After a long follow-up period of nearly
2 years, their report shows that more than half (57%)
of the 14 patients treated with this method were still
asymptomatic. The local fibrin glue injection method
has the obvious advantage of avoiding sphincter
complications. They concluded that, partly because
autologous fibrin glue was used, which seems to be
less effective than the heterologous form, the results
published to date on this method have not been very
encouraging when the patients were suffering from a
chronic inflammatory intestinal disease.
One-Stage Fistulotomy and Fistulectomy
Fistulotomy involves the deroofing or the laying
open of a fistulous tract along a probe. Fistulectomy
means excision of all the fistulous tract, granulation,
and dense fibrous tissue, creating larger wounds and
a greater separation of the ends of the sphincter,
which results in a longer healing time and increased
risk of incontinence. Fistulectomy and fistulotomy
are easy to perform in cases of perineal, intersphinc-
teric and low trans-sphincteric fistulae. If the fistu-
lous tract crosses the external sphincter, a lay-open
technique or fistulotomy results in some sphincter
damage, depending on the amount of sphincter
which is divided [64, 65].
After excision or incision of a fistulous tract, the
wound can be left open for healing by second inten-
tion. In some cases, a partial suture at the level of
the pectineal line and anoderm may achieve
haemostasis, speed up healing time and prevent an
anal key-hole deformity. The outer part of the exci-
sion is left open to ensure drainage. The wide inter-
study variability in success rates of surgery probably
depends on the non-homogeneity of the sample of
patients treated, but might also depend on the type
of fistula treated. Makowiec et al. [66] found the
healing rates after surgical treatment of low peri-
anal, transsphincteric and high perianal fistulae to
be 64, 40 and 33%, respectively. Moreover, absence
of active rectal Crohn’s disease decreased the recur-
rence rate and increased the probability of complete
healing. Due to the high incontinence rate and key-
hole deformity generated by these procedures, we
prefer to use the advancing flap technique in cases
of Crohn’s perineal fistulae, unless the fistulous
tract is quite distal.
Excision and Advancement Flap
When there is a high fistula, the primary tract across
the sphincters is excised and an advancement flap is
performed. This procedure consists of a conven-
tional fistulectomy, an opening of the intersphinc-
teric space through a partial excision of the internal
sphincter, occlusion of the former primary orifice of
the fistula and an advancement mucosal flap [67, 68].
Table 2. Use of biological glues in fistulae-in-ano
Reference N. of patients/ Success rate (%) N. of N. of
follow-up (months) CD patients successfully treated
CD patients
Hjortrup et al. [57] 23/31 74 0 –
Abel et al. [58] 10/12 60 3 0
Cintron et al. [59] 53/12 64 2 1
Venkatesh and
Ramanujam [60] 30/12 60 6 0 but 50%
improvement
Patrlj et al. [61] 69/28 74 0 –
Park et al. [62] 29/12 68 2 1
Sentovich [63] 20/10 85 4 3
Surgical Treatment of Perineal Crohn’s Disease 225
Technique
The first step consists of coring out the entire fistu-
lous tract from the external to the internal opening
(Fig. 8a). The intersphincteric space is curetted. The
gap through the external and internal sphincters is
closed by separate stitches of absorbable material
starting from the anal lumen (Fig. 8c). The mucosa
and anoderm, depending on the level of the tract, are
excised around the internal opening. A flap of mucosa
is undermined (Fig. 8b). The size of the flap must have
a base which is twice the width of the apex, but the
length should be as short as possible to reduce the risk
of ischemia. The flap is sutured to the lower edge of
the mucosa (Fig. 8d). The suture line must lie distal to
the previous muscle closure. The external wound is
left open. If the wound below the pectineal line cannot
be totally closed, the flap is sutured to the muscles
below the previous opening [69]. No stoma is neces-
sary. The external wound should be cleaned at least
twice daily with saline and some disinfectant solution.
This technique preserves a greater amount of sphinc-
ter than any other: it minimises scar formation,
avoids anatomic deformity such as keyhole deformity
and does not require any intestinal diversion. If a
recurrence of the fistula occurs, the procedure can be
repeated later. When the anorectal mucosa is mini-
mally inflamed and the Crohn’s disease is under con-
trol, with or without a reduced amount of steroids,
success rates from 40–60% can be expected [70–72].
In our experience of 42 patients treated with advanc-
ing flap technique, 23 patients (54.7%) were free of fis-
tula 1 year after the procedure. Functional results
confirm that this technique does not change the medi-
an maximal resting pressure nor the resting pressure
profile of the anal canal because the external sphinc-
ter is preserved and no keyhole deformity is created
[73]. After severe prior inflammation, extensive sub-
mucosal and even transmural fibrosis can make con-
struction of an advancement flap difficult. In some
complicated fistulae, the technique should not be the
primary treatment used. The situation should be sim-
plified by earlier surgery so that there is only a single
tract remaining. Finally, a previously drained supral-
evator fistula extending close to the rectal wall will not
leave enough residual tissue to support an advance-
ment flap. Using the flap technique in this situation
would lead to leakage at the suture and a recurrence
of the fistula.
Rectovaginal Fistulae
Rectovaginal fistulae occur in 3–10% of women with
Crohn’s disease [74, 75]. Most of these fistulae origi-
nate from an anterior rectal ulcer eroding into the
vagina, which usually occurs in the midportion of the
rectovaginal septum. These fistulae are the most diffi-
cult to treat and have a poor prognosis [76–78]. Less
commonly, these fistulae may arise from an infected
anal gland and they may travel superficially, through,
or above the sphincters. Bartholin’s abscesses may
also fistulise to the anorectum. This type of fistula car-
ries a poor prognosis [79]. Patients with rectovaginal
Fig. 8. Advancing flap tech-
nique. a Fistula tract is
cored out without sphinc-
ter division. b Excision of
the primary orifice and
removal of the entire tract.
c Liberation of a mucosal
flap and suture of the mus-
cular space. d Suture of the
mucosal flap
226 B. Roche, J. Robert-Yap
fistulae typically present with benign symptoms and
severe incontinence and excoriation are rare. Instead,
these patients complain of intermittent vaginal dis-
charge or the passage of gas through the vagina [76].
The diagnosis of these fistulae may be difficult. The
best test can be done during rectoscopy by injecting
air into the rectum and verifying its passage into the
vagina. In some cases, examination should be done
under anaesthesia. The treatment options in these
cases are reduced, in our point of view, to the advanc-
ing flap technique described previously.
Results
From 1994 to 2004 we treated 672 patients with anal
fistulae, of whom 59 (8.8%) had Crohn’s disease. The
male-to-female ratio was found to be 0.31 in Crohn’s
disease and 2.48 in idiopathic fistulae. The mean age
of the Crohn’s patients was 34 and 45 years for the
idiopathic fistula patients. On average, the Crohn’s
patients had twice as many fistulae and they were
generally more complex and the proportion of recto-
vaginal fistulae was higher at 14.2% vs. 2%. The most
frequent operations used in idiopathic fistulae were
fistulotomy or fistulectomy (71.8%), advancing flap
(27.7%) and glue sealant (0.5%). In Crohn’s disease
the respective proportions of these three techniques
were fistulotomy (10.2%), advancing flap (71.2%)
and glue sealant (18.6%). The median failure rates
were quite different: idiopathic fistulae (8.7%) and
Crohn’s fistulae (40.5%). One must always be aware
that early success may be followed by later recur-
rence, so scrupulous follow-up is necessary. The
main reason for using the advancing flap technique is
to preserve the anal profile and to maintain conti-
nence. However, even if there is a recurrence, the
potentially long intervals without perineal sepsis are
a benefit to the patient in their own right. As a sum-
mary of our work in this chapter we propose a non-
exhaustive algorithm for the treatment of perineal
Crohn’s disease (Fig. 9).
Summary
Anorectal disorders affect many patients with Crohn’s
disease. Clinical manifestations range from asympto-
matic skin tags to severe, debilitating perineal
destruction and sepsis. Surgical management must be
conservative and must focus on draining septic foci if
present, preserving sphincter function and palliating
symptoms. Medical management has shown some
success in improving symptoms but has not yet been
Fig. 9. Algorithm for treat-
ment of perineal Crohn’s
disease
Surgical Treatment of Perineal Crohn’s Disease 227
able to ameliorate most perineal complaints quickly
with long lasting effects. Many new and exciting treat-
ment modalities are being investigated, and it is
hoped that more effective approaches to these com-
plex and difficult problems will be found.
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Introduction
Ulcerative colitis (UC) is a chronic inflammatory dis-
ease of the colon affecting mainly young people, with
a peak incidence between the ages of 10 and 40 years;
15% of patients are over the age of 60 at diagnosis. Its
incidence is approximately 10–20 per 100 000 per
year with a reported prevalence of 100–200 per 100
000 and is stable over time. The value of prevalence is
less reliable, but it is probably underestimated
because it implies an average disease duration of
10 years for a condition that is known to last for life
[1]. A hospital serving a population of 300 000 will
typically see 45–90 new cases per year and have 500
under follow-up.
Patients find symptoms of UC and CD embarrass-
ing and humiliating. Inflammatory bowel diseases
(IBD) can result in loss of education and difficulty in
gaining employment or insurance [2]. It can also
cause psychological problems, growth failure or a
retardation in the sexual development of young peo-
ple. Medical treatments with corticosteroids or
immunosuppressants may cause major health prob-
lems, and surgery may result in complications such
as impotence or intestinal failure. There is only a
small increase in mortality for both UC (hazard ratio
1.44) and CD (hazard ratio 1.73), largely dependent
on age and extension of the disease [3]. However,
even if some patients have only functional symptoms
(which are not in themselves an indication to poten-
tiate the treatment and which may benefit from
symptomatic drugs such anti-diarrheals, anti-spas-
modics or fibres), the impact of IBD on society is dis-
proportionately high, as presentation often occurs at
a young age and has a potential to cause lifelong ill-
ness.
These considerations explain the peculiar expecta-
tions that patients with inflammatory bowel diseases
have concerning both the pharmacological treatment
and the overall clinical management. These consider-
ations and their rationale have been summarised in
recent clinical guidelines by the British Society of
Gastroenterology, and reported in Table 1 [4].
Therapy
The peculiar expectations of patients and the need of
a complex multidisciplinary approach to these
patients, support the referral of patients to units with
specific competence in this field. Therapy for IBD is a
rapidly evolving field with many new biological
agents under investigation that are likely to change
therapeutic strategies radically in the next decade.
We will try to summarise recent evidence concerning
the effect of the drugs and some warnings recently
outlined.
Aminosalicylates
Aminosalicylates act on epithelial cells via a variety
of mechanisms to moderate the release of lipid medi-
ators, cytokines and reactive oxygen species. These
drugs are available as oral tablets, sachets or suspen-
sion, liquid or foam enemas, or suppositories. Differ-
ent formulations deliver millimolar concentrations
to the gut lumen. Oral forms include:
– pH dependent release/resin coated mesalazine;
– time controlled release mesalazine;
– Delivery by carrier molecules, releasing 5-ASA
after splitting by bacterial enzymes in the large
intestine (sulfasalazine, olsalazine, balsalazide).
Mesalazine has been recommended both for induc-
ing and for maintaining remission.
Induction of Remission
Sutherland et al. [5, 6], in a meta-analysis of con-
trolled trials, observed that 5-ASA was superior to
placebo in active colitis (OR for maintaining remis-
sion 2). The same Authors, in an update of the afore-
mentioned meta-analysis, confirmed that 5-ASA was
superior to placebo for all outcome variables (glob-
al/clinical remission, global/clinical improvement,
endoscopic remission or improvement).
When 5-ASA was compared to sulfasalazine, there
Medical Treatment of Ulcerative Colitis
Fosca De Iorio, Luigi Benini, Naika Tacchella, Italo Vantini
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