S69 Case Report: Enterovesicle Fistulas and Their Presentation in Three Adolescent Males With Crohn's Disease

Abstract

Case: Background: Enterovesicle fistulas (EVF) in the setting of Crohn’s disease (CD) are uncommon. The aim of this poster is to shed light on the diagnosis and management (medical vs surgical) of EVF in pediatric populations. Methods: This poster compares 3 cases of adolescent males with Crohn's disease, their continued workup, and the difference in disease course in relation to the development of EVF. Results: Case 1: A 12-year-old male with known severe ileocolonic CD diagnosed at age 8, and a history of perianal and intra-abdominal abscesses and perianal fistula experienced recurrent urinary tract infection (UTI) 2 years into his diagnosis. A urine sample revealed stool, and magnetic resonance imaging (MRI) confirmed EVF. Exploratory laparotomy revealed inflamed and structured distal ileum with pre-stenotic dilation of proximal bowel, as well as the EVF. After surgical takedown, ileocectomy, and diverting ileostomy, he was started on infliximab. He has been on infliximab for 28 months with normalization C-reactive protein, normal linear growth curve, and no further episodes of structuring or penetrating CD. Cast 2: After years abdominal pain and growth failure a 16-year-old male (now 17) was diagnosed with Crohn's ileitis. After starting Infliximab, he began complaining of sediment and pneumaturia, which was confirmed on urinalysis (UA). He was taken to surgery for diagnostic laparoscopy where his cecum was found to be adherent to the bladder. Distal loop ileostomy was created. He is currently being treated with infliximab and doing well 1-month post-operatively. Case 3: A 22-year-old male was diagnosed with Crohn’s ileitis at age 13, after presenting with abdominal pain and weight loss. Before beginning medical therapy, he experienced dysuria and pneumaturia with visible stool in his urine sample. EVF was not seen on abdominal Computed Tomography (CT) scan. His EVF was confirmed on exploratory laparotomy, and he underwent EVF take-down, ileocecectomy, and diverting ileostomy, with subsequent successful ileostomy take-down. He was started on thiopurine post-operatively and has remained in remission on therapy for 9 years without no further disease exacerbations. Conclusions: The incidence of EVF among adults with CD ranges from 2% to 5%, although little is known about pediatric patients with EVF. In fact, only 2 case reports in children exist. EVF can be the presenting symptom of CD, or patients with known CD can present with recurrent UTI leading to diagnosis. The distinct symptoms of EVF, dysuria, pneumaturia and fecouria, make it easy to diagnose with UA and confirmatory cross-sectional imaging, although little is known about common sites of connection between the bladder fistula in children and how this affects presentation and management (10). In our 3 cases, patients received surgical intervention followed by aggressive medical management. With the advent and improvement of immunotherapy medications, research in adults has shown that EVF without severe complicating CD can sometimes be treated with medical therapy alone and experience EVF resolution (2,6-9). There is no clear consensus on clinical criteria for medical vs surgical intervention (7,8) so future studies in this area are needed.