Enterocutaneous fistula in severely active Crohn's disease: preoperative anti-TNF alpha treatment to limit bowel resection-report of a case.

PURPOSE: Strategies for limiting the extent of bowel resection in cases of enterocutaneous or interenteric fistulas in severely active Crohn's disease are urgently necessary. Anti-inflammatory therapy with tumor necrosis factor alpha (anti-TNF alpha) inhibitors has positive impact on fistulizing Crohn's disease. We describe a case of a 32-year-old male suffering from enterocutaneous fistula in severely active Crohn's disease.

METHODS: The patient's clinical course and data of therapy monitoring before bowel resection were reviewed and compared to the pretherapeutic findings. In addition, the reports of surgery and histopathological workup were evaluated and a clinical follow-up was performed. The literature on anti-TNF alpha treatment in fistulizing Crohn's disease was surveyed.

RESULTS: A 32-year-old male with an 8-year history of Crohn's disease and condition after previous ileocecal and sigmoid resection at the age of 28 presented with increasing pain in the middle-right abdomen. Laboratory and radiologic assessment detected elevated C-reactive protein and presence of a conglomerate of inflammatory thickened and narrowed small intestine involving the neoterminal ileum and enteroenteric fistulas. Ileocolonoscopy showed a stenosing inflammation of the neoterminal ileum. After initial anti-infective therapy, as a result of an interdisciplinary decision, preoperative anti-TNF alpha treatment was performed to achieve limited bowel resection. After declining of inflammation, limited bowel resection was carried out successfully.

CONCLUSIONS: Preoperative therapy with anti-TNF alpha might potentially reduce inflammation to subsequently limit the extent of bowel resection in selected cases of enterocutaneous or interenteric fistulas in severely active Crohn's disease. We describe an impressive case in which such therapeutic approach was carried out.