IV.5 Clinical case 5. Repeat fistulae and abscesses in a patient not diagnosed with inflammatory bowel disease

 

Abscesos y fístulas de repetición en paciente sin diagnóstico de enfermedad inflamatoria intestinal

 

INTRODUCTION

• The patient is a 49-year-old woman referred from the Surgery Department for evaluation of possible inflammatory bowel disease, given her history of multiple perianal surgeries during the past 5 years.

• The patient has smoked 20 cigarettes/day for over 10 years.

• She has no other relevant family history or habitual treatment.

• Furthermore, she has no digestive symptoms.

• She reports repeated perianal abscesses, with various perianal surgical interventions performed over the past 5 years: 3 previous fistulectomies, two abscess drainings, the last of which was 2 months ago with placement of 2 drainage setons, already removed.

• She is currently asymptomatic with no perianal discomfort.

 

PHYSICAL EXAMINATION

Evident scars from previous fistulectomy and from fistular orifices in the right perianal region, which are currently free of pain and drainage.

 

ADDITIONAL EXAMINATIONS

 

Lab tests

• Blood count with no abnormalities.

• Biochemistry: normal analytical parameters, except for C-reactive protein (CRP): 19.72 mg/l (normal range 0-5) and faecal calprotectin > 600 mg/g (normal range 0-50).

• Thiopurine methyltransferase activity (TPMT): 14.5 U/ml in red blood cells.

 

Ileocolonoscopy

A full colonoscopy was performed (Video 1), reaching the caecum, with no mucosal pathology observed in the colon. The endoscope was entered into the ileum, observing mild involvement, with ulcers, generally small in size, extending over no more than 10% of the examined section.  In the ileal region close to the valvular area, we observed a banded area
of ulcers and a deeper ulcer.

The endoscopic appearance suggest ileal Crohn’s disease with mild involvement.

Biopsies were taken.

Histological study

Ileum biopsy: acute and chronic ulceration and inflammation compatible with chronic inflammatory bowel disease (CIBD), specifically Crohn’s disease, with moderate activity.

 

Magnetic resonance enterography study

A resonance enterography study was performed following the ingestion of a polyethylene glycol solution and the intravenous administration of buscapina and gadolinium, with no involvement observed in the rest of the small intestine (Video 2).

 

FIRST RESONANCE STUDY OF THE PELVIS 

A complex perianal fistula was observed, defined by an intersphincteric fistula with a transsphincteric caecal branch towards the right ischioanal fossa. In high-resolution T2 weighted sequences, a hypersignal was observed from the two tracts, related to inflammatory activity (Fig. 1).

 

 

 

Clinical impression

Crohn’s disease with mild inflammatory involvement of the ileum and recurrent perianal disease with inflammatory activity (Montreal Classification: A3L1B1p).

 

Therapeutic approach

We established treatment with antibiotics (ciprofloxacin and metronidazole in combination) and azathioprine, and performed the biologic agent protocol (Mantoux, chest X-ray, serology) to decide whether to start anti-tumour necrosis factor (anti-TNF) treatment based on progress. In addition, the patient quit smoking completely, as per medical advice.

Her initial progress was good and she remained asymptomatic, with no perianal pain or drainage for the first 5 months, after which a new superficial abscess requiring surgical drainage appeared. We therefore requested a new pelvic resonance study to evaluate placing drainage setons and the need for biologic treatment.

 

SECOND RESONANCE STUDY OF THE PELVIS (Fig. 2)

We performed another pelvic resonance study with contrast, comparing it to the previously-performed study (from 6 months earlier). It showed good progress, with decreased signs of inflammatory activity in the fistulous tract.

 

 

Therapeutic approach

The patient is currently asymptomatic again, with no pain or drainage.

On viewing the results of the resonance study, with improved inflammatory parameters for the fistulous tracts and even scarring/partial fibrosis in some segments, we decided not to start anti-TNF treatment for the moment and to continue following-up on the patient’s clinical-radiological progress.

 After one year, the patient remained asymptomatic, under azathioprine treatment, with her analytic parameters including CRP and calprotectin remaining normal. Over this last year, no perianal symptoms appeared, with the patient remaining in clinical remission.
 

THIRD RESONANCE STUDY OF THE PELVIS (Fig. 3)

Therapeutic approach

We performed another repeat resonance study after one year, in which the patient had remained asymptomatic, with no perianal symptoms, comparing the study to previous resonance studies and observing scarring in the fistulous tracts.

The patient has not required treatment with anti-TNF drugs so far and has remained in clinical remission for 18 months, experiencing adequate radiological progression with scarring of the internal fistulous tracts. We can thus say that this case is in complete fistula remission.

Since diagnosis of the disease, she has continued not to smoke.

She will remain on maintenance treatment with azathioprine, under clinical follow-up.

 

 

 

SUPPORTING SCIENTIFIC UPDATE

• I.1.6. Assessment of perianal fistulous disease

• II.3.1. Pelvic resonance study in perianal disease

• II.3.2. Endoanal ultrasound in perianal disease