P-017 YI Spontaneous Closure of Enterovesicular Fistula with Adalimumab

Abstract

Crohn’s disease is a chronic inflammatory disorder which affects approximately 700,000 patients in the United States. Of these patients, up to 40% will have fistulizing disease, which represent a more aggressive phenotype often failing medical therapy and requiring surgery for definitive treatment. We present 2 cases of fistulizing Crohn’s disease complicated by entero vesicular fistula successfully treated with Adalimumab monotherapy. Case 1: 23 y/o male who presented to Walter Reed National Military Medical Center (WRNMMC) with a 4 month history of RLQ pain, relapsing fevers, pneumaturia and dysuria. Evaluation via CT Scan of the Abdomen was significant for long segment terminal ileitis with evidence of an entero-vesicular fistula. Colonoscopy showed nodular and erythematous terminal ileal mucosa with biopsies confirming Crohn’s ileitis. Cystoscopy revealed an area of erythematous and edematous mucosa along the posterior bladder wall. An initial prolonged course of Ciprofloxacin and Metronidazole partially improved symptoms. The patient was started on Adalimumab induction dosing followed by 40 mg subcutaneously bi-weekly with complete resolution of symptoms over the course of 2 months. Subsequent MRE showed no evidence of fistulous tract along with significant improvement in small bowel disease. The patient remains in clinical remission approximately 1 year after initiation of Adalimumab. Case 2: 27 y/o male who presented to WRNMMC with a 1 month history of dysuria, fecaluria, hematuria and scant hematochezia. Patient was initially evaluated at Landsthul Army Medical center, Germany where he underwent cystoscopy which showed evidence of ulcerative cystitis and a fistulous tract. Colonoscopy was significant for cobblestone appearing terminal ileum with ulcerated mucosa. Biopsies showed crypt abscess formation and distortion consistent with Crohn’s ileitis. Patient was initially placed on Ciprofloxacin and metronidazole with no improvement in symptoms. MR enterography (MRE) showed the presence of an entero-vesicular fistula with associated distal ileal inflammation. The patient was started on Adalimumab induction dosing followed by 40 mg subcutaneously every other week. Over the course of 4 months the patient reported complete resolution of all symptoms. Re-evaluation with cystoscopy was notable for no residual fistula and MRE approximately 8 months later demonstrated no evidence of an entero vesicular fistula. Enterovesicular fistulas occur in 2%–5% of patients with Crohn’s disease. When present, typical symptoms include recurrent urinary tract infections, pneumaturia and fecaluria. Surgical management is often necessary but can have serious complications such as perforation and abscess formation in as many as 12% of patients. In patients in whom medical management is attempted, there have been limited reported cases of successful closure of enterovesicular fistulas with anti TNF agents. These 2 cases represent the only reported sustained successful management of enterovesicular Crohn’s fistulas confirmed by both clinical response and radiographic evidence on anti-TNF therapy. The early use of anti-TNF in a patient presenting with a fistula (“top-down” approach) may be the reason fistulas healed so effectively. Use of anti-TNF therapy should be considered early in the treatment of fistulizing Crohn’s to include enterovesicular fistulas.