Case 9. Management of perianal Crohn’s disease



A 58-year-old male with no disease antecedents of interest initially manifested intense anal pain, the appearance of a fistula with purulent discharge, and rectal bleeding. The laboratory tests showed no alterations. Colonoscopy revealed a patchy distribution of deep and extensive ulcers up to the transverse colon, with normal interlesional mucosa. The histological findings were consistent with Crohn’s disease. Treatment was started with antibiotics (combination ciprofloxacin 500 mg/12 h and metronidazole 250 mg/8 h), and an MRI study was carried out. (Reference 1. Utilities MRI and perianal disease)

Figure 1. MRI revealed a left trans-sphincter fistula with an abscessified trajectory, intense gadolinium uptake in T2-weighted sequencing and involvement of the ischioanal fossa. Based on these findings, the patient was referred for surgery to complete the procedure by exploration under anesthesia; cleaning was carried out, and a seton was placed in the fistular tract to facilitate drainage and progressive closure.

Maintenance treatment was started with azathioprine, with a favorable course – the patient remaining free of pain and with abundant spontaneous drainage. After three months of treatment with azathioprine, the patient remained free of pain, though external drainage continued. The addition of infliximab was therefore decided, followed by a very good response and cessation of the external drainage.

Figure 2. After the cessation of external fistular drainage, MRI control showed the disappearance of inflammatory activity along the internal fistular trajectory. The draining seton was therefore removed.

Figure 3. Current appearance of the external fistular orifice. The patient has been asymptomatic and in remission for over two years. Management presently consists of azathioprine monotherapy.


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