Complicated Crohn’s disease: An unusual destination of an enterocutaneous fistula

Abstract

A 26-year-old female with history of
untreated Crohn’s disease, presented with
right lower back pain and fecal drainage
from the right retro-sacral area. It started
as a painful pimple that progressed to an
abscess. After antibiotic treatment failure,
the abscess opened up and drained fecal
material. A computed tomography scan of
the abdomen and pelvis showed severe rightsided
hydroureteronephrosis (Figure A),
and a large pelvic abscess (7.7x6.4x8.5 cm)
involving the sigmoid colon and small bowel
(Figure B - label 1), with contiguous spread
into right gluteal musculature (Figure B
-label 2), and subcutaneous tissue superficial
to the lumbosacral spine (Figure C).

Laparotomy surgery revealed severe
inflammation in the terminal ileum (TI)
and cecum along with TI perforation.
Ileocecectomy with end-ileostomy was
performed. Large bowel obstruction due
to severe rectal inflammation and stricture
was noted, and a diverting loop-colostomy
in the sigmoid colon was created. Liquid
stool-filled pelvic abscess was drained, and a
fistula extending from deep pelvis lateral to
sacrococcyx, up through back muscle planes,
ended with a superficial abscess and cutaneous
orifice over the lumbosacral area, and was
extensively debrided. A 30 cm wound vacuum
was placed over laparotomy incision. The
patient had uneventful post-surgical recovery
and is planned to start biologic therapy.