1575 Colouterine Fistula: A Rare Crohn's Complication

Abstract

INTRODUCTION: Colouterine fistulas are a rare complication of gastrointestinal diseases, mostly described as a complication of diverticulitis in elderly patients. Colouterine fistula as a complication of Crohn's disease is exceptionally rare. We present a young Caucasian female with history of poorly controlled Crohn's disease presenting with colouterine fistula. CASE DESCRIPTION/METHODS: 26-year-old Caucasian female with ileal Crohn's disease since 2014 presented with abdominal pain and fever. Her PMH was significant for poor compliance with medications and follow ups. In the preceding 6 months she had a complicated clinical course including a flare with SBO and intraabdominal abscess while she was 23 weeks pregnant needing resection of TI and cecum with a diverting ileostomy followed 2 weeks later by a miscarriage, drainage of a perirectal abscess, fistula between loops of small bowel, and ileostomy take down followed by an abdominal wall abscess needing drainage. She had been lost to follow up and had not been on any medications the preceding one year. Her last colonoscopy was prior to ileostomy take down and had shown healthy appearing ascending colon stump, mild erythematous mucosa throughout the colon with no pathologic evidence of Crohn's and a well healing perianal fistula site. At presentation, ESR was 70 mm/h and CRP 81 mg/L. CT abdomen was read as a large peripherally enhancing fluid collection within the right lower abdomen and pelvis and mildly thickened neoterminal ileum. An abscessogram however showed the fluid collection was a large colouterine fistula filling the ascending colon at the anastomosis and both Fallopian tubes. Patient has been started on induction therapy with adalimumab and discharged with slow prednisone taper with plans to follow up for continued adalimumab therapy as well as evaluation at a facility with specialty Uro-Gynecology resources for fistula correction. DISCUSSION: Fistulas between small bowel and uterus in Crohn's disease has been described in literature. Fistulas between colon and uterus in Crohn's disease is exceptionally rare; to date only two cases have been reported, a sigmoid colouterine fistula and rectouterine fistula. The thick uterine wall is considered to be a protective factor against fistula formation, but prior colonic surgery or disruption of uterine wall integrity may predispose to fistula formation in Crohn's disease. Our patient had a recent ileocecectomy which was likely contributory to colouterine fistulization in the setting of poor compliance.