Complicated fistulizing Crohn’s disease in a high-risk patient

Abstract

Introduction. Crohn's disease (CD) is a type of inflammatory bowel disease (IBD) with symptoms that may include abdominal pain, diarrhea, fever and malnutrition. Fistulizing Crohn’s disease represents one of the most severe complications in CD, with an increase in its frequency of diagnosis. Case presentation. We report the case of a 39-year-old woman known with grade B Los Angeles esophagitis, duodenal ulcer, hiatal hernia, previous H. pylori gastritis, diagnosed with ileal Crohn’s disease (specific endoscopic aspect and confirmed histopathology result) in early 2020. Three months after her diagnosis and the initiation of the specific treatment (corticotherapy), the patient presented with severe abdominal pain, 7-8 stools/day, with mucus and blood, and the presence of fecaluria. MRI examination shows inflammatory changes in the terminal ileum, several entero-enteral fistulas, and the presence of an abscess at the level of the fistula located between the ileum and the urinary bladder. Treatment with Metronidazole was initiated for 10 days, with an improvement in the paraclinical assessment. The patient underwent surgery with evacuation of the abscess, right hemicolectomy with terminal ileostomy, segmental sigmoid resection, suture of the urinary bladder and drainage of Douglas and parietocolic space. Two months later following up MRI revealed a calcified liquid collection in the parietocolic space and ileocolic anastomosis was performed. The evolution of the patient requires a treat to target approach which will include early initiation of biological treatment with Infliximab after the surgical recovery process. Discussion. Differential Diagnosis should be made with ulcerative colitis, in which fistulas are also a known complication, but happening less common. Conclusion. This case illustrates the importance of close follow-up after surgery in patients with fistulizing Crohn's disease, as well as the significance of biological treatment in the management of complications in high-risk patients. A close follow-up can help to detect early recurrence and prevent further fistula development and abscess formation.