Management of Perianal Crohn’s Disease

A 30-year-old man with a 2-year history of Crohn’s disease (CD) involving the distal ileum and left colon is evaluated for a 2- to 3-week history of perianal pain and drainage. In the past, his disease was well controlled with oral mesalamine medications. He underwent a colonoscopy 1 month before this visit and was noted to have active proctitis for which mesalamine suppositories were started. On physical examination there is mild left lower-quadrant tenderness. Rectal examination is significant for an open fistula at 7 o’clock (posterior-right) that easily expresses purulent material with gentle pressure on the tract. Digital rectal examination is painful and shows an area of fluctuance within the anal canal posteriorly at 6 o’clock.