McGaw Medical Center of Northwestern University Chicago, IL, United States
Joy Liu, MD1, Eula Tetangco, MD, MPH1, Rebecca Obeng, MD, PhD, MPH1, Vitaliy Poylin, MD1, Stephen B. Hanauer, MD2 1McGaw Medical Center of Northwestern University, Chicago, IL; 2Feinberg School of Medicine, Chicago, IL
Introduction: While fistulizing disease in Crohn’s disease (CD) affects 20-50% of patients, involvement of gynecologic structures, which may cause pelvic cysts, masses, or abscesses, is rare. Fewer than 20 cases of granulomatous ovarian disease and 5 cases of entero-salpingeal fistulizing disease have been reported in the literature. We present a case of Crohn’s disease with tubo-ovarian abscess and ileo-salpingeal fistula managed with abscess drainage and surgery.
Case Description/Methods: A 22-year old female with history of right ovarian cyst, endometriosis, and 20-pound weight loss was found to have a right adnexal multiseptated lesion concerning for contained ileal perforation with abscess and new Crohn’s disease. After being started on antibiotics and budesonide, the patient was lost to follow-up. On presentation two years later, MRI showed ileocolic fistula with multiple pelvic fluid collections, including one adjacent to the right ovary read as peritoneal inclusion cyst. Infliximab with azathioprine improved symptoms, but weight loss continued to a nadir of 71 pounds. Imaging showed persistent ileal thickening, ileocolic fistula with sinus tracts into a 7-cm right enterotubal abscess, right ovary, and pelvic fluid collections. A pelvic drain was placed and total parenteral nutrition (TPN) was started. The patient was taken to the operating room, where terminal ileum disease fistulizing to a rectosigmoid abscess and right fallopian tube with an inflammatory rind surrounding the right ovary were found. Right salpingectomy with ileocecectomy, ileocolic anastomosis, and enterocolic and enterotubal fistula repair were performed, with right ovarian sparing.
Discussion: CD may clinically and radiographically overlap with gynecologic conditions such as endometriosis, ovarian cysts, and pelvic inflammatory disease. Gynecologic CD should be strongly considered when there are ipsilateral bowel wall abnormalities. Gastroenterologists, surgeons, and radiologists should be involved in multidisciplinary care. If a patient with CD develops a pelvic abscess, TNF-a inhibitors should be avoided and appropriate antibiotics initiated. Surgery or drainage should be considered. Management of fistulas is surgical; oophorectomy can be avoided if there is no fistulization to the ovary itself. Patient desire for fertility preservation should be assessed. More evidence on the effect of fistulizing disease on ovarian reserve and fertility are needed.
Figure: Initial contrast-enhanced MRI shows large fluid collection (asterixes) read as peritoneal inclusion cyst at the site of later pelvic abscess (A). Follow-up MRI shows ileal disease, enterocolic fistula (arrow) (B) and sinus tract (arrow) appearing to extend into right Fallopian tube or ovary suggestive of enterotubal fistula and abscess (C). Operative pathology shows salpingeal inflammation with granuloma formation at 100x (D) and 200x (E).
Disclosures: Joy Liu indicated no relevant financial relationships. Eula Tetangco indicated no relevant financial relationships. Rebecca Obeng indicated no relevant financial relationships. Vitaliy Poylin indicated no relevant financial relationships. Stephen Hanauer indicated no relevant financial relationships.
Joy Liu, MD1, Eula Tetangco, MD, MPH1, Rebecca Obeng, MD, PhD, MPH1, Vitaliy Poylin, MD1, Stephen B. Hanauer, MD2. P0603 - Entero-Tubal Fistula and Abscess in the Setting of Crohn’s Disease, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
