Fibrin Glue Treatment of Enterocutaneous Fistula in Crohnʼs Disease

Abstract

Background: Crohn's disease is an auto-immune inflammatory condition that can affect any portion of the gastrointestinal tract from the mouth to the perianal area. Fistulas occur in up to 25% of all Crohn's disease patients. Fibrin glue has been used to treat fistulas refractory to conventional medical therapy to avoid more radical surgical intervention. Case: A 27-year-old male with a 10 year history of Crohn's disease complicated by an enterocutaneous fistula presented with 2 weeks of foul-smelling abdominal drainage. His fistula involved the cecum and had been present for 1 year despite medical therapy. Past medical history was significant for a partial small bowel resection of the terminal ileum & ileocecal valve and perianal fistulas s/p Seton placement. He was on adalimumab, but not continuously due to financial issues. CT of his abdomen and pelvis confirmed the presence of an enterocutaneous fistula without abscess within the region of the cecum. He underwent a colonoscopy with fibrin glue injection and endoclip closure of the enterocutaneous fistula. A colonoscope was passed to the cecum; a small opening was seen which was traversed with the colonoscope. A fistula probe was inserted into the fistula opening on the skin; the probe was visualised with the colonoscope thus confirming the fistula tract. 1ml of fibrin glue was back filled through the fistula tract using an injection catheter. Two endoclips were subsequently applied to the internal portion of the fistula. He was discharged home without adverse events. At follow-up 6 months later, there was no abdominal drainage from the fistula tract. Magnetic resonance enterography confirmed closure of the fistula, without evidence of intra-abdominal abscess or fluid. Discussion: Fibrin glue is a two-component system in which a solution of concentrated fibrinogen and factor XIII is combined with a solution of thrombin and calcium to form a coagulum which is designed to mechanically seal a fistula tract. Instilling fibrin glue into fistulas is a simple and safe procedure which does not preclude the use of other techniques or repeat procedures in the case of failure. Several studies have been published of series of patients treated with fibrin glue and success rates vary from 0% to 80%. This variability can be attributed to the different types of fistulas treated, differences in the definition of healing, variable sample sizes and duration of patient follow-up. Given the low morbidity and relative simplicity of the procedure, it should be considered as an alternative to surgical resection of a persistently draining fistulous tract. More well-designed controlled studies are required to confirm the effectiveness of this emerging treatment.