Fournierʼs Gangrene Complicating Inflammatory Bowel Disease: Is it Ulcerative Colitis or Crohnʼs Disease?

Abstract

Purpose: A 62-year-old man with history of ulcerative colitis presented with scrotal pain and swelling. Patient denied pneumaturia, abdominal pain, diarrhea, fever/chills, or overt GI bleeding. Past medical history was significant for type 2 diabetes and ulcerative colitis. He reported multiple perineal fistulas with recent Fournier gangrene requiring serial debridements over the last 2 months. He was afebrile with stable vitals. Abdominal exam was notable for suprapubic tenderness, multiple open ulcers and discharging fistulas in the perineum. Several scars from prior fistulas were noted. MRI showed horseshoe shaped perirectal abscess and multiple perineal fistulas. Colonoscopy showed anal stenosis and a fistulous opening in the rectum. Remaining colon appeared normal. Rectal biopsies showed mildly increased plasma cells and eosinophils within lamina propria with mild architectural distortion, and patchy mild acute inflammation without granulomas. Based on clinical presentation and findings, patient was diagnosed with fistulizing Crohn's perianal disease with rectal involvement. He underwent surgical debridement with suprapubic catheter placement and was started on metronidazole, ciprofloxacin and inflixmab with good response. Discussion: Perianal Crohn's disease affects 25-40% of all Crohn's patients and includes anal fissures, perianal fistulas, anorectal abscesses, and anal stenosis. Perianal fistula affects 20-30% of all Crohn's patients. Diagnostic tests include: exam under anesthesia with probing, fistulography, barium studies, CT, pelvic MRI, and anorectal EUS. Oral metronidazole for 6-12 months followed by gradual taper can be used as initial therapy for mild to moderate disease. For severe or refractory disease, anti-TNFs agents such as infliximab or adalimubab, have been shown to reduce the number of draining fistulas and even achieve complete closure. Response is rapid with median time to response of 2 weeks. Immumodulators such as 6-MP or azathioprine have also been shown to achieve complete healing or decrease discharge but response is much slower. Only three cases of IBD complicated with Fournier's gangrene have been reported in the literature. Of these two had undiagnosed Crohn's disease and one had ulcerative pancolitis who developed Fournier's gangrene after perianal surgery. Management involves serial debridements, broad spectrum antibiotics, anti-inflammatory therapy for IBD, and diversion colostomy in severe cases.