A 32-year-old man with known Crohn's disease (ileocolonic, perianal fistulae) on mesalazine presents with worsening perianal pain and a fistula draining purulent material. MRI pelvis confirms a complex supra-levator fistula with associated perianal abscess. CRP is 68 mg/L. What is the correct sequence of management?
- A Surgical drainage and seton placement THEN biological therapy (infliximab) ✓
- B Start infliximab immediately and avoid surgery
- C Azathioprine alone for 3 months then reassess
- D Total colectomy for perianal Crohn's
Correct answer: A. Surgical drainage and seton placement THEN biological therapy (infliximab)
Explanation
For complex perianal fistulizing Crohn's disease with abscess, the correct management sequence is: (1) surgical drainage of sepsis and seton placement first — starting biologics in the presence of undrained sepsis risks serious infectious complications including septic shock; (2) followed by induction anti-TNF therapy (infliximab) after sepsis is controlled. The ACCENT II trial established infliximab maintenance as effective for fistula closure. Azathioprine alone is insufficient. Starting infliximab before draining active sepsis is explicitly contraindicated.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.