A NOVEL APPROACH TO THE ENDOSCOPIC REPAIR OF AN ENTEROCUTANEOUS FISTULA IN A PATIENT WITH CROHN’S DISEASE

Abstract

Abstract Introduction Enterocutaneous fistula (ECF) is an abnormal connection that develops anywhere between the gastrointestinal tract and the skin. Fistulae most commonly occur in the context of inflammatory bowel disease. Standard definitive management involves surgery and biologic therapy. We present a case of an ECF treated with endoscopic and medical management. Case Presentation A 34-year-old man with Crohn’s disease with prior colectomy and ileorectal anastomosis presented with abdominal pain. CT enterography demonstrated a fistulous tract from the bowel to the anterior abdominal wall concerning for ECF. He subsequently underwent sigmoidoscopy with confirmation of ECF on the ileal side of his anastomosis. He was started on metronidazole 500 mg three times a day, azathioprine at 175 mg daily, and adalimumab 40 mg every other week in attempts to close the fistulous tract, however the patient reported continued drainage. Surgical correction was offered. However, in attempts to avoid surgical resection, he underwent sigmoidoscopy, where the tract was identified. A cytology brush was introduced into the fistula and used to irritate the epithelial layer to promote scarring. Next, doxycycline was injected through a scleroneedle into the track as a sclerosing agent. Argon plasma coagulation (APC) of the fistula internal os and surrounding tissue was performed, followed by deployment of 2 hemoclips to promote closure of the internal os. Initially there was closure but 2 months later there was recurrence of ECF. Sigmoidoscopy was repeated with administration of doxycycline to sclerose the tract, followed by APC to the tissue adjacent to the internal os, and the placement of a hemoclip to oppose the tissue around the internal os. Following endoscopic treatment, the patient’s ECF has remained healed. Since ECF closure, he has been in endoscopic and clinical remission for over 4 years. Discussion This approach was successful in the treatment of ECF. Doxycycline has been used for treatment of recurrent pleural effusions, lymphatic malformations and lymphoceles due to its sclerosing properties. Mechanism of action is unknown, but it is believed to be due to the induction of an inflammatory reaction that results in fibrosis and ablation of endothelial-lined cavities. APC has been used in the treatment of gastrointestinal conditions, including angiodysplasias and colonic polyps post polypectomy. There is limited evidence discussing its effectiveness of endoscopic fistulous repairs. Our experience reviews that the combination of biologic therapy and endoscopic therapeutic options are a successful option in the treatment of ECF. While surgical resection remains a treatment option, patient’s typically favor less invasive strategies. Further studies should investigate endoscopic closure of fistulous tracts in order to provide more treatment modalities to our patients.