A 29-year-old woman presented with intermittent abdominal pain of three months duration with weight loss of 5 kg.
The patient was diagnosed with Crohn's ileitis and symptoms disappeared after steroid treatment.
Five months later she presented with iron deficiency anemia and severe malnutrition.
CAT scans and small intestine transits showed extra intestinal tracts from cecum/terminal ileus to posterior planes suggestive of fistulas.
Treatment was established with enteral nutrition, metronidazole and low-dose corticosteroids.
The patient had a good evolution, but ten months later she came for suppuration at the level of the glue and retroperitoneal abscess so it was decided to perform surgery with ileocecal resection and ileocolic anastomosis laterolateral.
1.
In CD, three approaches have been described in the treatment of abscesses: medical treatment with antibiotics and steroids, percutaneous drainage and surgery with resection of affected intestinal segments.
Initial medical treatment would be based on the use of 5-ASA, antibiotics and corticosteroids, azathioprine or 6-mercaptopurine in case of refractory to conventional treatment (2).
The following line of treatment is based on the use of infliximab (monoclonal anti-TNF-a antibody) and a reduction in the number of surgical interventions has been observed in this group of patients.
A therapeutic alternative for patients with fistulizing Crohn's disease refractory to treatment with anti-TNF-a would be the use of partial anticalcineurinic agents such as tacrolimus with complete remissions of up to 40% (3).
Radiologically guided percutaneous drainage at this time became the main therapeutic alternative, even obviating the need for intestinal resection.
However, they can present up to 100% of relapses (4).
Some authors defend that definitive treatment of psoas abscess should also include resection of the affected portion of the digestive tract (5).
In the two cases of fistulizing CD with intra-abdominal abscesses presented, we have been able to observe two types of experiences regarding its treatment.
In the first case, the abscess could be resolved after surgical drainage and conservative treatment.
In the second case, we had no opportunity to treat the patient with anti-TNF because the clinical picture occurred in 1999 and surgical treatment was the best option, after failure of conservative treatment.
In conclusion, patients with fistulizing CD with the presence of intra-abdominal abscesses can be treated conservatively initially, in some cases, either with radiological drainage or treatment with anti-TNFta agents.
Surgical resection of the diseased intestinal loop would be reserved for cases with failure of conservative medical treatment or recurrence of fistulous CD (6).
1.
M. Valdés Mas, J. A. Pons Miñano and F. Carballo Álvarez
Gastroenterology Service.
Hospital Universitario Virgen de la Arrixaca.
Murcia,
