Hi all,
In the response to Bernhard recent post about final correct diagnosis of the cause of his ongoing anal pain and chronic fissures, I did some research and found couple of interesting research papers.
I thought it might be interesting for some members and maybe worth of looking into as possibility since that cohort of patents would need different approach and different treatments that might give them lasting relief.
Introduction

Anal involvement can be the initial presentation in up to 5% of patients with Crohn's disease, and over a lifetime as many as one third of patients will have symptoms or complications from involvement of the anoperineal region. From a purist's viewpoint, anal involvement is different from rectal disease. However, for practical purposes, rectal involvement is frequently considered part of anoperineal disease. Traditionally, the treatment of patients with Crohn's disease has focused on decreasing symptoms, improving quality of life, and decreasing complications related to either the disease process or its therapy. Anal and perianal complications of Crohn's disease represent a major challenge for both the gastroenterologist and colorectal surgeon.
Anoperineal disease is one manifestation of Crohn's disease that significantly adversely affects patient quality of life. The spectrum of involvement includes prominent perianal skin tags, fissures, ulcers, abscesses, fistulas, and stricture -- at times, disease can be so extensive that it leads to destructive lesions of the anoperineum. Fistulas can be internal, external, or mixed; single or multiple; or simple or complicated. Anoperineal involvement can lead to social isolation because patients have urgency, frequency, and stool incontinence that can be related to either the disease itself or the iatrogenic complications. Other symptoms include pain, soiling, sleep disruption, sexual dysfunction, and sepsis. The treatment of patients with anoperineal disease frequently entails stool diversion by the creation of a stoma to improve symptoms and manage infectious complications, or placement of noncutting seton sutures that allow for continued open drainage of purulence.
It is important to use a multidisciplinary approach to optimally evaluate and treat these patients. The gastroenterologist and the colorectal surgeon must work together, given that adequate examination under anesthesia and surgical treatment of septic complications are often both needed in addition to long-term medical therapy. Prior to initiating therapy, the type of fistulous disease must be classified. This usually involves a colorectal surgery examination under anesthesia (EUA) and an endoscopic ultrasound of the anoperineum to determine the extent of fistulous disease and the degree of involvement of the anal sphincters. Once the type and extent of involvement has been determined, a rational approach to management can be devised that should include: (1) medical treatment for simple or complex fistulas with active mucosal inflammation or (2) surgical-medical treatment for fistulous disease and sinuses, disease complicated by abscess, disease with a minimal inflammatory component, and disease in which an internal os cannot be visualized.
Whether this strategy will lead to a better outcome than medical or surgical treatment alone has not been determined. To design and perform a trial to evaluate the efficacy of this approach would be very difficult, given the large number of patients and long follow-up that would be required. However, with the information currently available, we propose the following algorithm as a means of approaching the treatment of patients with Crohn's disease involving the anoperineal region:
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Figure.
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Figure.
The review titled "Treatment of Perianal Crohn's Disease: State of the Art," by Dr. Schwartz and Dr. Sandborn in this issue of Medscape Gastroenterology carefully presents the existing information on the medical therapy of perianal Crohn's disease. Such therapy will only be effective if all of the septic material is drained during EUA and if surgical therapies, such as advancement flap surgery or mushroom catheter placement, are deemed inappropriate. When surgical therapy is appropriate, however, recent series have reported a 70% long-term success rate, without the need for potent and potentially toxic immunosuppressive agents.
Treatment of perianal Crohn's disease remains a great challenge for clinicians and offers an excellent opportunity for gastroenterologists and colorectal surgeons to cooperate for the delivery of optimal patient care.
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Authors and Disclosures
Aaron Brzezinski, MD,
and
Bret A. Lashner, MD,
Center for Inflammatory Bowel Disease,
Department of Gastroenterology,
Cleveland Clinic Foundation
Cleveland, Ohio
Brzezinski A, Lashner BA. Treatment of Perianal Crohn's Disease: State of the Art. MedGenMed 2(3), 2000 [formerly published in Medscape Gastroenterology eJournal 2(3), 2000]. Available at: http://www.medscape.com/viewarticle/407956

Fantastic, Fissy! Yes, there are some - we know who you are -- who DO need a different approach...thanks so much for this post! :)

You are welcome Kim
I really hope this might bring help to long-time sufferers - they have to "push" doctors to do further tests and also try to make them try different meds , even as a "trail" !!! Many diseases can not be confirmed, in general, but doctors still make a "working diagnosis" , meaning - one "in progress" and try meds to see if they might help. That way they get correct diagnosis "in reverse" order - but better ever than never !!!

Fiss,
What an article! Have never b/4 heard of Perianal Crohn's Disease. I do know that at the time my son with CD was first diagnosed via colonoscopy, he had 3 ulcers in the colon and one was in the rectal area.
Fortunately, docs are learning more about diagnosing and treating IBD, and I am still trying to get the word out about the first CCFA walk in our area.
IBD patients suffer BIG TIME. It's a horrible disease, unlike "just" having an AF which can get cured by using creams, soaks, Botox, or even LIS. Going to the annual symposiums has helped me a lot because I realize now how many people have IBD issues. Like AF's IBD is not something that people often discuss with others.

The video on this link brought tears to my eyes because it really hit home for me:
http://online.ccfa.org/site/PageServer?pagename=spreadtheword_main

Thanks Cheryl !!!
Yes - it is horrible how many people suffer with all kind of maladies and one would expect that doctors practicing in 2010 would have more answers to offer , but unfortunately, that is not the case
BUT - fund raising and activists like you can make a huge difference in many areas of research and medicine !!! Kudos to all people who are involved in such organizations and selflessly devote their time and effort to make a change

Thanks, but, of course, I selfishly support my various causes because of my son. I've been feeling lately that I have a "job" even though I don't because I have several different areas right now that are keeping me busy with advocacy! I just need to continue to tell myself, like you indicated, that there are many horrible maladies--the list is endless--and many different people have their own causes about which they feel passionate (or apathetic or indifferent!). :roll:

Yes...unfortunately many are indifferent : (((. Just the "health reform" atempt that went so bad : (( showed how little empathy there is in this country for the vulnerable and sick : (((. Just horrible !!!!!! : (((