Multiple Enteroenteric Fistulas: Crohnʼs Disease

Abstract

A 39 years old Pakistani male with a past history of significant crohn's disease since last 18 years presented to ER with severe supra pubic abdominal pain, dysuria, pneumaturia and fecal contamination of urine. He had occasional nausea and vomiting, crampy abdominal pain with bloating associated with meal intake and occasional diarrhea leading to significant weight loss of 15 pounds over the previous 1-2 months.He was medically managed on infliximab for approximately 10 years but switched later to cetolizumab due to episodes of exacerbation between the doses. The next drug also failed after 1-2 months as he started having acute episodes in the last few months. He had pre-operative colonoscopy, a year ago, after that exploratory laparotomy was recommended with possible resection of diseased bowel and stricturoloplasty by his primary GI physician but he denied it. He completed a 2 week course of ciprofloxacin plus metronidazole and a week course of prednisone for his symptoms and became asymptomatic with the treatment. One week after completion of symptomatic treatment he became symptomatic again and has been progressively getting worse. CT scan with contrast showed moderately distended small bowel, compatible with small bowel obstruction, due to significant inflammatory edematous thickening of the terminal ileum. There was evidence of multiple enteroenteric fistulas. Also there was an inflamed small bowel loop inseparable from the superior wall of bladder with presence of gas in the urinary bladder demonstrating evidence of enterovesicular fistula. The overall configuration suggested complications related to chronic inflammatory bowel disease. Colonoscopy a year ago showed classic features of chronic inflammatory disease with tubulization in the cecum, ascending colon and proximal transverse colon as well as sigmoid colon and rectum. The distal transverse colon and the entire descending colon appeared to be free of obvious disease. A flat carpet like polyp was also seen at ano-rectal junction. Crohn's disease involves the gastrointestinal tract from mouth till anus. Skip lesions, fistula formation and transmural involvement of colonic wall are features of the disease. Adequate medical and surgical treatment can keep the disease in remission and prevent acute exacerbations. This case reports multiple eneteroenteric and enterovesicular fistulas in asian patient suffering from long term crohn's disease however this disease is very rare in asian population with such an advanced involvement of gastrointestinal tract involving urinary tract as well.Figure 1Figure 2