weekly_question 9/7/2023

[Admin]

A 5-year-old boy undergoes incision and drainage of a perianal abscess. He is discharged home and completes a course of oral amoxicillin/clavulanate (Augmentin). The boy returns to your clinic 4 weeks later with a persistently draining perianal fistula at the 5 o’clock lithotomy position. He has no further pain or fevers.

The most appropriate next step is:

A Observation alone as the fistula will likely close spontaneously

B Fistulotomy as the fistula will not likely close spontaneously

C Referral to Pediatric Gastroenterology for workup of Crohn’s Disease

D Empiric oral steroid therapy

[Admin]

correct answer
C Referral to Pediatric Gastroenterology for workup of Crohn’s Disease

This child’s presentation is highly suspicious for perianal Crohn’s Disease. This diagnosis should be considered in any school-age child or adolescent with a perianal abscess, regardless of family history. These patients should be referred to Pediatric Gastroenterology for workup of Crohn’s Disease and initiation of anti-TNF therapy. If a draining Seton was inserted at the time of the incision and drainage procedure, then this should be left in place until the patient is stabilized on a biologic medication.

Fistulotomy should be avoided in patients with possible perianal Crohn’s Disease as this can result in a chronic, non-healing wound. Observation alone is an appropriate option in an infant with a spontaneous perianal abscess, as there is no known association with Crohn’s Disease, and these lesions almost always heal without surgical intervention. The decision to start medical therapy in the absence of a definitive diagnosis of Crohn’s disease (such as starting empiric steroids) should be left to the discretion of the Pediatric Gastroenterology team.

[Batool]

A Observation alone as the fistula will likely close spontaneously

[Mohamed ahmed Abd elsalam]

A

[Manal Dhaiban]

B

[Ismailmohamed]

A

[Admin]

correct answer
C Referral to Pediatric Gastroenterology for workup of Crohn’s Disease

This child’s presentation is highly suspicious for perianal Crohn’s Disease. This diagnosis should be considered in any school-age child or adolescent with a perianal abscess, regardless of family history. These patients should be referred to Pediatric Gastroenterology for workup of Crohn’s Disease and initiation of anti-TNF therapy. If a draining Seton was inserted at the time of the incision and drainage procedure, then this should be left in place until the patient is stabilized on a biologic medication.

Fistulotomy should be avoided in patients with possible perianal Crohn’s Disease as this can result in a chronic, non-healing wound. Observation alone is an appropriate option in an infant with a spontaneous perianal abscess, as there is no known association with Crohn’s Disease, and these lesions almost always heal without surgical intervention. The decision to start medical therapy in the absence of a definitive diagnosis of Crohn’s disease (such as starting empiric steroids) should be left to the discretion of the Pediatric Gastroenterology team.

[Admin]

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