eP559 - Enterocutaneous Fistula and Pancreatitis in the Initial Diagnosis of Crohn's Disease: A Case Report

Purpose/Background: Inflammatory bowel disease (IBD) is a rare entity comprised of two main disorders: ulcerative colitis (UC) and Crohn's disease (CD). It can affect any portion of the gastrointestinal tract, from mouth to perianal area. Initial clinical manifestations usually include abdominal pain, diarrhea, fever and weight loss, and very unusually cutaneous fistulas can be seen as such, as well as several extraintestinal manifestations. This wide range of clinical manifestations lead to diagnostic difficulties.
Patients with CD are at an approximately fourfold higher risk than the general population of developing acute pancreatitis. This can occur before onset of intestinal disease; however, it usually occurs after intestinal symptoms have manifested.Methods/Interventions: We present the case of an otherwise healthy 24-year-old male who began with a three-month evolution of weight loss, diffuse abdominal pain, asthenia and changes in evacuation patterns with progressive symptoms up to 1 month prior. The patient showed non-specific feverish peaks as well as increased volume and erythema in the infraumbilical region, which subsequently presented fluid leakage with fecaloid characteristics. The patient then seeks medical evaluation in our institution.
Paraclinical tests reported chronic anemia and elevation of c-reactive protein. During hospitalization, there was an increase in volume and supraumbilical erythema with subsequent leakage of fecaloid fluid, following the appearance of a second fistulous tract. Contrast-enhanced abdominal CT scan reported a fluid collection adjacent to the sigmoid colon which fistulized the abdominal wall.
The patient was initially started on treatment with broad-spectrum antibiotic therapy and parenteral nutrition and was admitted to the operating room, where an exploratory laparotomy was performed. Adhesion of the sigmoid colon to the pelvic floor was evident, with the presence of fistulization. A sigmoidectomy with terminal colostomy was performed.Results/Outcomes: The patient later presented postoperative elevation of serum amylase. Serum lipase and abdominal CT scan were requested with a diagnosis of acute pancreatitis, which is handled and resolved. The rest of the postoperative period passed without eventualities and adequate tolerance to the oral route. A report of pathology of the surgical specimen was collected reporting chronic colitis with moderate activity and acute non-perforated diverticulitis consistent with CD. The patient remains asymptomatic in the postoperative surveillance, being discharged with outpatient follow-up by surgery and gastroenterology services.Conclusion/

Discussion: CD can develop penetrating complications at any time during the disease course. Up to 35% of patients may be diagnosed with at least one fistula, with only up to 6% of these being enterocutaneous as the least common with an important impact on quality of life. We as surgeons must always be aware of differential diagnosis in patients with enterocutaneous fistulae and work as a multidisciplinary group together with gastroenterology specialists.
In this case our patient developed acute pancreatitis in the postsurgical period during his hospital stay. This case helps emphasize the importance of early identification of the multiple risk factors as unlikely as they may be, such as CD, for developing acute pancreatitis and the role that these factors play, so as to not overlook them."Illustration 1 Initial abdominal CT scan

Showing abdominal collection adjacent to the sigmoid colon with fistulization towards the abdominal wall
Illustration 2 patient´s abdominal wall

presence of two fistulous tracts"