CROHN'S DISEASE AND CUTANEOUS FISTULA: CASE REPORT

Case Presentation A 62-year-old woman presented with purulent secretion from a spontaneous opening in the right iliac fossa (RIF) for the past 3 months, associated with fever episodes, refractory to antimicrobial therapy. She had a history of right ileocolectomy 28 years ago for the treatment of an enterocutaneous fistula, at which time she was diagnosed with Crohn's disease (CD). She was on vedolizumab treatment. Abdominal enterography revealed a posterolateral enterocutaneous fistula near the iliac portion of the iliopsoas muscle. After adequate nutritional support and correction of anemia, the patient underwent exploratory laparotomy – multiple adhesions and blocked perforation of the sigmoid colon, firmly adhered to the retroperitoneum on the right side, where an abscess adjacent to the psoas muscle was found, with a fistulous tract leading to the abdominal wall. A Hartmann's sigmoidectomy and abdominal cavity drainage were performed. The postoperative period was uneventful.

Discussion CD can affect any part of the gastrointestinal tract (GIT), manifesting with inflammatory, stenosing, or penetrating phenotypes. Around 14% to 26% of patients develop fistulous processes. Of these, 24% will develop enter-enteric or enterocolonic fistulas, and only 6% will develop enterocutaneous or colocutaneous fistulas. The occurrence of two or more fistulas happens in less than one-third of cases and indicates severe CD. Fistula diagnosis requires contrast-enhanced imaging for better anatomical definition. The treatment of CD with the penetrating phenotype requires a multidisciplinary approach that integrates pharmacological and, sometimes, surgical therapies, along with nutritional support. The goal is to control inflammation, promote healing, and prevent sepsis, which is the main factor associated with morbidity and mortality. The treatment of immunological dysregulation includes biologic drugs, immunosuppressors, and corticosteroids. In the case of enterocutaneous or colocutaneous fistulas, surgical intervention is performed in 75% to 85% of cases and aims to restore GIT continuity, ensure proper coverage of the soft tissues surrounding the intra-abdominal content, and close the external opening. Intestinal loop fistulas are treated surgically only if symptomatic, which occurs in about 6% of cases.

Conclusion This case illustrates the complexity of managing fistulas associated with CD, highlighting the need for a personalized multidisciplinary approach, especially in patients with severe disease.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025