Case 5: 24-year-old female with fistulizing Crohn’s disease

VISIT #1

VISIT 1 Visit to gastroenterologist office in over 2 years

Initially Crohn’s disease was discovered in her 3 years ago. At that time the inflammation was in the terminal ileum. The treatment was with prednisone and azathioprine (Imuran). Because the patient was feeling so well she decided to stop her medications 2 years ago.

3 months ago the patient was noticing pain at her buttocks when she would sit. This pain got worse each time she had a bowel movement. 2 months ago something ‘burst’ in the area where the pain was located. Since then she has noticed similar pain from this site, as well as a mucus/bloody drainage from this area.
The doctor looks at this site and determines that this problem is from a fistula:
To make better understand what is happening a MRI of the pelvis is ordered:
– For treatment a 6 week course of antibiotics (ciprofloxacin, and metronidazole) is ordered.
– Azathioprine is restarted
VISIT #2

VISIT 2 2 month follow up appointment (2 weeks after the MRI is complete)

The patient is not feeling much better. Her pain and drainage from the site has not improved. The patient is very worried about the lack of progress.
MRI reveals a pocket of infected fluid (called an abscess) with a fistula in the area of pain.

A surgeon needs to look at this are under anesthesia to drain this infected fluid and put a thread in the fistula to keep it draining so further abscesses don’t form.
VISIT #3

VISIT 3 4 weeks after the surgery

The patient’s pain has improved, but the drainage is still present and bothersome.
The surgeon drained the abscess.

Because the infected fluid has been drained it is now safe to start medical therapy to close the fistula. The doctor recommends restarting the azathioprine and starting an antiTNF medication (adalimumab or Infliximab). The doctor calls this combination therapy
VISIT #4

VISIT 4 3 months after starting combination therapy

The patient’s pain remains controlled and the drainage has essentially stopped.
The physician cuts the thread that was keeping the fistula tract open to allow the tract to completely close.
Fistulas related to Crohn’s disease can be very hard to deal with.

The best approach to treat fistula is to first make sure there is no pocket of infection. Once this has been dealt with then using combination therapy (anti-TNF agent with azathioprine) is the most appropriate therapy.