Crohn Disease: Lichtenstein GR

Lichtenstein GR, Hanauer SB, Sandborn WJ, Anonymous00070. · Department of Medicine, Division of Gastroenterology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. · Am J Gastroenterol. · Pubmed #19174807 No free full text.

Abstract: Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When data that will withstand objective scrutiny are not available, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. Given the wide range of choices in any health-care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee. Expert opinion is solicited from the outset for the document. The quality of evidence upon which a specific recommendation is based is as follows: Grade A: Homogeneous evidence from multiple well-designed randomized (therapeutic) or cohort (descriptive) controlled trials, each involving a number of participants to be of sufficient statistical power. Grade B: Evidence from at least one large well-designed clinical trial with or without randomization, from cohort or case-control analytic studies, or well-designed meta-analysis. Grade C: Evidence based on clinical experience, descriptive studies, or reports of expert committees. The Committee reviews guidelines in depth, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time.

Blonski W, Lichtenstein GR. · No affiliation provided · Gastrointest Endosc. · Pubmed #16500403 No free full text.

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Baidoo L, Lichtenstein GR. · No affiliation provided · Am J Gastroenterol. · Pubmed #15654785 No free full text.

Abstract: The use of infliximab (Remicade) has revolutionized the care of Crohn's disease (CD) patients who have proved refractory to standard treatment. The use of infliximab is very well tolerated in the majority of patients but in a small subset of patients may lead to the production of antibodies (termed "antibodies to infliximab"-ATI). The production of these antibodies has been associated with the development of both acute and delayed infusion reactions, although even in patients who develop ATIs, these reactions are relatively uncommon. Nonetheless, these reactions may occasionally be severe enough to lead to intolerance to infliximab. Another group of patients, after initially having excellent responses to infliximab, experience an attenuated response or loss of response over time. What is the cause of this loss of efficacy? ATIs may play a role in some patients but other potential reasons for this phenomenon have provoked much debate. The importance of other cytokines after TNF-alpha has been neutralized may be relevant as (this has been shown to be the case in rheumatoid arthritis (RA) is the idea of beneficial autoimmunity production to TNF-alpha. (Wildbaum G, Nahir MA, Karin N. Beneficial autoimmunity to proinflammatory mediators restrains the consequences of self-destructive immunity. Immunity 2003;19:679-88.) It has been shown that during the course of an autoimmune condition, the immune system mounts a beneficial autoantibody response to proinflammatory mediators. This response counteracts, to a certain degree, the autoimmune pathology. This natural counteraction has been illustrated in animal models of autoimmunity, and there has been evidence demonstrated that this occurs in human RA. Whether this occurs in Crohn's is unknown; infliximab is a chimeric monoclonal antibody containing an approximately 25% murine region. It had been hoped that the development of humanized or fully human monoclonal antibodies would provide therapeutic antibodies that did not induce an immune response. While this has unfortunately not proven to be the case-these products still have significant immunogenicity-these products do present an alternative therapy when infliximab cannot be used. In light of this, adalimumab (Humira) a human monoclonal antibody used for treating rheumatologic conditions has been investigated as an alternate treatment for patients with CD who after initially responding to infliximab experience intolerance or loss of efficacy. Is this a viable alternative?

Su C, Lichtenstein GR. · No affiliation provided · Am J Gastroenterol. · Pubmed #11151860 No free full text.

This publication has no abstract.

Sandborn WJ, Feagan BG, Lichtenstein GR. · Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA. · Aliment Pharmacol Ther. · Pubmed #17877506 No free full text.

Abstract: BACKGROUND: Patients with Crohn's disease alternate between periods of active, symptomatic disease and periods of remission. The treatment goal for Crohn's disease is to induce and then maintain remission of symptoms. AIM: To review evidence from randomized, controlled, clinical trials on medical therapies for inducing and maintaining remission in patients with mild-to-moderate Crohn's disease, and to suggest the best evidence-based approaches for induction and maintenance therapies. METHODS: PubMed search using the following terms: sulfasalazine or salicylazosulfapyridine or aminosalicylate or aminosalicylic acid or mesalamine or mesalazine or corticosteroid or prednisone or prednisolone or methylprednisolone or budesonide or antibiotic or metronidazole or ciprofloxacin or immunosuppressive or azathioprine or mercaptopurine or thiopurine or methotrexate and Crohn's disease. RESULTS: Randomized, controlled trials demonstrated that sulfasalazine, budesonide, and conventional corticosteroids are effective for inducing remission of mild-to-moderate Crohn's disease when administered for a period of 8-16 weeks. An ideal maintenance therapy does not currently exist. CONCLUSIONS: Selection of maintenance therapy is based on a combination of evidence from controlled trials and patient features including disease severity and location, co-morbidities, previous response to treatment, and previous surgical resection. The options for maintenance therapy include therapy cessation and patient observation following successful induction, budesonide, or immunosuppressive therapy.

Osterman MT, Lichtenstein GR. · Division of Gastroenterology, Department of Medicine, Penn Presbyterian Medical Center, University of Pennsylvania School of Medicine, 218 Wright Saunders Building, 39th and Market Streets, Philadelphia, PA 19104, USA. · Gastroenterol Clin North Am. · Pubmed #17129814 No free full text.

Abstract: The treatment of fistulizing CD has evolved greatly in the last 15 years, largely caused by improvements in medical therapy. Tables 2 and 3 summarize all published controlled and uncontrolled trials of immunomodulator and biologic therapy for the treatment of Crohn's fistulae. The advent of immunomodulators and anti-TNF-alpha agents has transformed the treatment of Crohn's fistulae from almost exclusively surgical to placing a much larger emphasis on medical therapy, either as initial therapy alone, with surgery reserved for refractory cases, or in combination with surgery from the start. For this reason, surgeons and gastroenterologists must work in concert to provide the best care for each patient. Proper fistula management also relies heavily on accurate diagnosis, especially defining the anatomy of the fistula, ascertaining whether abscess formation is present, and determining the location and extent of intestinal inflammation.

Chang JT, Lichtenstein GR. · Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA. · Nat Clin Pract Gastroenterol Hepatol. · Pubmed #16582964 No free full text.

Abstract: In the past decade, advances in the understanding of the pathogenesis of inflammatory bowel disease have permitted the development of agents directed against rational therapeutic targets. In particular, various antagonists of tumor-necrosis factor-alpha have been developed. These include infliximab, adalimumab, certolizumab (CDP870), CDP571, etanercept, and onercept. Clinical trials of these agents have demonstrated varying degrees of clinical efficacy. The use of these agents can be limited by infection, immunogenicity, acute infusion reactions, delayed hypersensitivity reactions, and autoimmune phenomena. This review provides insights into the use of antagonists of tumor-necrosis factor-alpha for the treatment of inflammatory bowel disease.

Blonski W, Lichtenstein GR. · Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. · Curr Opin Gastroenterol. · Pubmed #16319674 No free full text.

Abstract: PURPOSE OF REVIEW: The purpose of this review is to analyze the complications associated with treatment of inflammatory bowel disease with biologic agents. RECENT FINDINGS: There have been various biologic agents evaluated in patients with inflammatory bowel disease; that is, Crohn's disease and ulcerative colitis. Thus far only infliximab has been approved by the US Food and Drug Administration as induction and maintenance treatment in patients with active Crohn's disease (moderate-to-severe and/or fistulizing) who are refractory to conventional therapy. Recent data from two large multicenter, multicountry, randomized controlled clinical trials have demonstrated that infliximab is efficacious also for the treatment of ulcerative colitis. Other biologics considered potentially efficacious are still undergoing evaluation in various clinical trials. SUMMARY: The data concerning biologics' associated toxicity in patients with inflammatory bowel disease are the most robust in the case of infliximab. These data are derived from both prospective, randomized clinical trials and from post-marketing experience. In the case of the remaining agents the data concerning safety in inflammatory bowel disease are limited, as these agents were not evaluated in as many trials as infliximab; indeed, some of them included only several patients.

Lichtenstein GR. · Department of Medicine, Hospital of the University of Pennsylvania, School of Medicine, PA, USA. · Am J Gastroenterol. · Pubmed #15984959 No free full text.

This publication has no abstract.

Bewtra M, Lichtenstein GR. · University of Pennsylvania Health System, 100 Centrex, IMR, 3400 Spruce Street, Philadelphia, PA 19104, USA. · Expert Opin Biol Ther. · Pubmed #15934836 No free full text.

Abstract: Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract. The disease can be quite severe, resulting in hospitalisation, requiring long-term treatment with a variety of medications and frequent surgeries. Infliximab is a chimeric monoclonal antibody directed against tumour necrosis factor, a key cytokine in the inflammatory cascade of many diseases, including Crohn's disease. Numerous studies have shown significant improvement in both clinical and endoscopic luminal and fistulising Crohn's disease with infliximab treatment. The clinical efficacy, indications, safety profile and future of infliximab are reviewed.

Blonski WC, Katzka DA, Lichtenstein GR, Metz DC. · Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia 19104, USA. · Eur J Gastroenterol Hepatol. · Pubmed #15756097 No free full text.

Abstract: Many gastric acid hypersecretory states (basal acid output of greater than 15.0 mEq/h) exist for which the etiology is known, such as Zollinger-Ellison syndrome, systemic mastocytosis, antral exclusion, antral predominant Helicobacter pylori gastritis (antral G cell hyperplasia), chronic gastric outlet obstruction, short gut syndrome and basophilic leukemias. However, many hypersecretory patients have no identified etiology for their acid hypersecretion and are designated as idiopathic gastric acid hypersecretors with a basal acid output of greater than 10 mEq/h and a normal serum gastrin level. Because of the gastric acid hypersecretion these patients also commonly have an increased frequency of stools. Idiopathic gastric acid hypersecretion represents a known cause of gastric acid hypersecretion that is far more common than Zollinger-Ellison syndrome and it has a markedly different treatment regimen and natural history. We report a case of a patient with idiopathic gastric acid hypersecretion previously misdiagnosed as having Crohn's disease because of a presenting complaint of diarrhea and mimicking Zollinger-Ellison syndrome because her fasting serum gastrin level was elevated when incorrectly measured in the presence of antisecretory treatment.

Su C, Lichtenstein GR. · Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4283, USA. · Adv Drug Deliv Rev. · Pubmed #15555740 No free full text.

Abstract: Infliximab (Remicade) is an antitumor necrosis factor (TNF) therapy effective in both induction and maintenance of remission in Crohn's disease. Identifying predictors of response or relapse to infliximab is important given the potential toxicities and cost of this therapy. Currently available data suggest that concurrent immunosuppressant therapy, certain clinical characteristics, biological and immunological markers, and gene polymorphism may correlate with response to infliximab. However, no single variable has been consistently shown or definitely proven in studies to be a predictor of response to infliximab to be of practical value in current clinical practice. Data from the literature in these areas are reviewed in this article, pointing to the need for additional research in this topic.

Lichtenstein GR. · University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA. · Gastroenterology. · Pubmed #15521022 No free full text.

This publication has no abstract.

Lichtenstein GR, Hanauer SB, Kane SV, Present DH. · University of Pennsylvania School of Medicine, Philadelphia, PA, USA. · Inflamm Bowel Dis. · Pubmed #15475770 No free full text.

Abstract: Crohn's disease is an idiopathic, chronic inflammatory disorder of the digestive tract with heterogeneous clinical presentations. Crohn's is currently not a curable disease, and patients are faced with a lifetime of recurrent disease flare-ups and remissions. Management strategies for Crohn's must therefore be targeted toward lifelong management, taking into consideration not only the short-term but also the long-term aspects of the disease. With this in mind, here we review the classifications and natural history of Crohn's disease and discuss possible predictive factors for the disease evolution in a patient. Here we also evaluate the current preferable treatment practices, based on scientifically valid research and collective clinical experience, for the management of mild to moderate Crohn's disease.

Judge TA, Lichtenstein GR. · Gastroenterology Division, Robert Wood Johnson Medical School, Cooper University Hospital, University of Medicine and Dentistry of New Jersey, 401 Hadden Avenue, Room 374, Camden, NJ 08103, USA. · Gastroenterol Clin North Am. · Pubmed #15177547 No free full text.

Abstract: The primary goals of the clinician in the treatment of fistulizing Crohn's disease (CD) include (1) defining the anatomy of the fistula, (2) draining any associated infectious material, (3) eradicating the fistulous tract through medical or surgical therapies, and (4) preventing recurrence of fistulas. Evaluation and therapeutic decisions require close collaboration between the gastroenterologist and surgeon. Appropriate evaluation should include identification of septic complications, delineation of the fistulous tract including the origin and terminus of the fistula, and determination of the extent of bowel involvement with active CD. Drainage of abscesses and control of septic complications through the placement of drains or setons is essential. Conservative therapy with avoidance of sphincter muscle-cutting procedures is the standard approach. The appropriate approach to asymptomatic patients is uncertain because there are little data to indicate if treatment alters the natural course of disease.

Su C, Lichtenstein GR, Krok K, Brensinger CM, Lewis JD. · Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, UPenn Medical Center-Presbyterian, 218 Wright-Saunders Building, 39th & Market Streets, Philadelphia, PA 19104, USA. · Gastroenterology. · Pubmed #15131785 No free full text.

Abstract: BACKGROUND & AIMS: Placebo-controlled, randomized clinical trials (PC-RCTs) are commonly used to assess therapies for Crohn's disease (CD). Knowledge of the placebo rates of remission and response and understanding of design factors that influence these rates is important for designing future clinical trials evaluating pharmacotherapy of CD. The aims of this study were to estimate rates of remission and response in patients with active CD receiving placebo and to identify factors influencing these rates. METHODS: We performed a systematic review and meta-analysis of PC-RCTs evaluating therapies for active CD identified from MEDLINE from 1966 to 2001. RESULTS: The pooled estimates of the placebo rates of remission and response were 18% (95% confidence interval, 14%-24%; range, 0%-50%) and 19% (95% confidence interval, 13%-28%; range, 0%-46%), respectively, both with significant heterogeneity among studies (P < 0.01 for remission, P < 0.03 for response). In multivariate models, study duration, number of study visits, and entry Crohn's Disease Activity Index score were important predictors of the placebo remission rate, with study duration the most important. However, no single factor could account for all of the heterogeneity. Factors that influence the placebo response rates were similar to those affecting the placebo remission rates. The absolute benefit of active treatment beyond placebo was generally larger when outcome was measured by response than remission. CONCLUSIONS: Placebo remission and response rates in PC-RCTs for active CD are variable. Study duration, number of study visits, and disease severity at entry have a large influence on placebo remission rates.

Srinivasan R, Lichtenstein GR. · Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, USA. · Expert Opin Investig Drugs. · Pubmed #15102587 No free full text.

Abstract: Therapy for Crohn's disease (CD) is rapidly evolving with the emergence of new discoveries in disease pathogenesis. Since the approval of the first biological agent, infliximab, there have been several others that have been studied and are available for use within the context of clinical trials, in CD patients who do not respond to conventional medications or whose disease cannot be maintained in remission with the use of infliximab. The number of available drugs that have focused on the inhibition of TNF is growing. To avoid the injectable route of administering biologicals, several oral agents, such as thalidomide analogues, nonabsorbable antibiotics, such as rifaximin, and specific antibiotics, such as ornidazole, are being studied and considered for patients with CD. Hormonal therapies, such as growth hormone, coherin, medroxyprogesterone acetate and dehydroepiandrosterone, are other novel therapies for CD. Immunomodulators in use in other fields of medicine, including tacrolimus, 6-thioguanine and leflunomide, are being evaluated for the treatment of patients with CD and are also discussed. Several other promising therapies, such as cyclophosphamide, extracorporeal photochemotherapy, stem cell transplantation and the use of porcine whipworm, add to the available therapeutic armamentarium of this life-long remitting and relapsing disease. The future for CD patients is promising with the ever-expanding repertoire of drugs that are being studied.

Su C, Lichtenstein GR. · Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Third Floor Ravdin Building, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA. · Med Clin North Am. · Pubmed #12510462 No free full text.

Abstract: The evolving medical armamentarium holds promise for more precise and effective therapies for IBD. The experience with anti-TNF therapy, particularly infliximab, illustrates the potential efficacy of therapies targeted at specific mediators or pathways involved in the pathogenesis. Advances in molecular technology have enabled the development of novel and potentially effective targeted therapies. Equally important is the increasing scientific understanding of the pathogenesis of IBD, which will likely improve the ability to stratify disease and to select therapies based on genotypic, immunologic, and phenotypic profiles in the future.

Judge TA, Lewis JD, Lichtenstein GR. · Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 3rd Floor Ravdin Building, Philadelphia, PA 19104-4283, USA. · Gastrointest Endosc Clin N Am. · Pubmed #12486941 No free full text.

Abstract: Extracolonic malignancies are a relatively rare complication of inflammatory bowel disease. In contrast, colorectal cancer remains a major concern for patients with long-standing UC. The best available evidence suggests that patients with long-standing Crohn's colitis are at similar risk for colorectal cancer as those patients with long-standing UC. In patients with UC, the magnitude of this increased risk appears to be greater in patients with more extensive colonic involvement. It appears that the magnitude of this risk increases with increasing duration of disease, at least in UC. Whether this reflects the increased risk of cancer that occurs with the aging process or a separate phenomena distinct to UC is unclear. To date, the methods available to reduce the risk of cancer are less than optimal. Although surgical procedures eliminate the risk, the mental and physical sequelae of these procedures can be substantial. Surveillance with colonoscopic biopsies is likely effective in reducing although not eliminating the risk of colorectal cancer. Efforts to develop chemopreventative agents and improved surveillance methods remain areas of active investigation.

Lichtenstein GR. · Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. · Rev Gastroenterol Disord. · Pubmed #12478240 No free full text.

Abstract: Patients with inflammatory bowel disease (IBD)-either Crohn's disease (CD) or ulcerative colitis (UC)-are at increased risk for developing cancers of the gastrointestinal tract, particularly colorectal cancer (CRC). Because of the relative rarity of IBD in the general population, it has been difficult to quantify this risk; nonetheless, within particular subsets of IBD patients, the cumulative risk of developing dysplasia and CRC may be substantial. Efforts to reduce this risk have included both prophylactic surgery and endoscopic screening programs. Despite the impact this disease has on quality of life and life expectancy, an optimal strategy for reducing the risk has yet to be defined. This article reviews the current literature relating to the risk of cancer for patients with IBD and methods available to help reduce this risk.

Yang YX, Lichtenstein GR. · Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia 19104-4283, USA. · Am J Gastroenterol. · Pubmed #12003413 No free full text.

Abstract: Crohn's disease is a lifelong illness characterized by chronic recurrent flares. The precise etiology of Crohn's disease is unknown. However, it appears to involve an enhanced systemic immune response and intensified local intestinal mucosal inflammatory activity, mediated through various inflammatory cells and an array of proinflammatory cytokines. Corticosteroids have been the mainstay of treatment of Crohn's disease. The controlled trials of the National Cooperative Crohn's Disease Study and the European Cooperative Crohn's Disease Study established that corticosteroids were effective for the induction of remission in Crohn's disease for the duration of the studies (6-17 wk). However, corticosteroids have not been shown to have an impact on the maintenance of long term remission in patients with Crohn's disease. In addition, they are associated with a high potential for dependence and serious toxic side effects. Alternative classes of medical therapy for Crohn's disease, including modified corticosteroids and a group of new biological therapies, have proven to be efficacious in the management of active and/or quiescent Crohn's disease.

Lichtenstein GR. · Department of Medicine, Center of Inflammatory Bowel Diseases, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, 3 Ravdin Building, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA. · J Pediatr Gastroenterol Nutr. · Pubmed #11685972 No free full text.

This publication has no abstract.

Lichtenstein GR. · Department of Medicine/Gastroenterology, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia 19104-4283, USA. · Inflamm Bowel Dis. · Pubmed #11380040 No free full text.

Abstract: Corticosteroids are considered a drug of choice for the treatment of patients with moderately to severely active Crohn's disease (CD), an inflammatory bowel disease characterized by chronic recurrent flares of disease activity. However, among patients receiving corticosteroid therapy for induction of remission, 20% have corticosteroid-refractory disease and 36% of those with an initial response develop corticosteroid dependency within 1 year. Chronic corticosteroid exposure in patients who are corticosteroid dependent increases the risk for serious drug-related adverse effects. Withdrawal or reduction of corticosteroid therapy without exacerbation of symptoms is therefore recognized as an important goal of treatment. Therapies that have been shown to facilitate "steroid sparing' include the immunomodulators azathioprine/6-mercaptopurine and methotrexate and the antitumor necrosis factor-alpha monoclonal antibody infliximab. In corticosteroid-dependent patients, budesonide may be substituted for conventional corticosteroid therapy without loss of response and with less risk for toxicity, but its long-term efficacy requires further evaluation. A preliminary controlled study suggests that the investigational anti-TNF monoclonal antibody CDP-571 may also be clinically beneficial as a corticosteroid-sparing agent. This review summarizes the clinical evidence that supports consideration of these agents as alternatives in patients with CD who are dependent on, refractory to, or intolerant of conventional corticosteroid therapy.

Stein RB, Lichtenstein GR. · University of Pennsylvania School of Medicine, and Department of Medicine, Presbyterian Medical Center, Philadelphia, USA. · Surg Clin North Am. · Pubmed #11218170 No free full text.

Abstract: Various medications are used to control the symptoms of Crohn's disease. This article reviews the traditional medical therapies of Crohn's disease, including aminosalicylates and corticosteroids, and the broad armamentarium of immune modulators and biologic agents that are becoming increasingly important in the management of Crohn's disease.

Lichtenstein GR. · Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104-4283, USA. · Gastroenterology. · Pubmed #11040200 No free full text.

Abstract: The appropriate treatment of patients with fistulas in the setting of Crohn's disease requires a knowledge of the specific medical and surgical literature of fistulizing Crohn's. The patient with symptomatic fistulizing Crohn's disease may respond differently to specific medical therapy than a patient with symptomatic obstructing Crohn's disease. Certain medications that are useful for the treatment of patients with obstructive Crohn's disease may not be helpful in the treatment of fistulas in patients with fistulizing Crohn's disease (e.g., corticosteroids and mesalamine); in fact, some medications are believed to be detrimental (e.g., corticosteroids). Few studies have been performed to assess the efficacy of specific medications on fistulas directly. To date, there has been only one published prospective randomized controlled trial that was designed to assess the efficacy and safety of a specific medication on fistulas in patients with Crohn's disease; it showed clinical efficacy over placebo in a statistically significant manner. The judicious use of surgery remains an integral part of the management of certain presentations of fistulizing Crohn's disease, and the appropriate integration of surgical and medical therapy is of paramount importance in the management of these patients. This review provides an overview of pertinent medical and surgical literature as it pertains to management of patients with fistulizing Crohn's disease.