Crohn Fistula

Crohn fistulas result from transmural inflammation penetrating into adjacent bowel, bladder, vagina, skin or other structures.

Common abdominal fistulas include:

Enteroenteric
Enterocolic
Enterovesical
Enterovaginal
Enterocutaneous

A radiological fistula alone is not necessarily an indication for surgery. The indication is driven by symptoms, sepsis, obstruction, malabsorption and the anatomy of the diseased donor segment.

Enteroenteric fistulas may remain asymptomatic.

Enterocolic fistulas can bypass substantial absorptive bowel and cause diarrhoea or malnutrition.

Enterovesical fistulas produce pneumaturia, recurrent urinary infection and faecaluria.

Enterovaginal fistulas cause passage of enteric material or gas through the vagina.

Fistulas associated with fever, focal pain or systemic inflammation should be assumed to have an associated abscess until excluded.

Control sepsis before definitive reconstruction.

Drain associated abscesses and optimise nutrition.

Asymptomatic enteroenteric fistulas without obstruction or malabsorption can sometimes be observed during medical treatment.

Surgery becomes appropriate with:

Enterovesical fistula
Significant enterovaginal fistula
Associated stricture
Associated abscess
Persistent sepsis
Malabsorption from bypass
Symptomatic enterocutaneous fistula
Medically refractory disease.

At surgery, resect the diseased Crohn segment that created the fistula. The target organ may need only limited repair if otherwise healthy.

For an enterovesical fistula, limited bladder closure is sufficient when a clear bladder defect remains after bowel separation. Extensive bladder resection is unnecessary unless the bladder itself is diseased.

Avoid en bloc removal of healthy adjacent organs simply because they are adherent to penetrating Crohn disease.

Temporary diversion may be appropriate when there is severe sepsis, poor tissue quality, malnutrition or high anastomotic risk.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Crohn Abscess

A Crohn abscess results from penetrating transmural disease with a contained perforation and intra abdominal or pelvic pus collection.

It commonly coexists with a diseased ileal segment, stricture or fistula. Antibiotics alone often fail when a mature collection remains undrained.

The preferred sequence is control of infection first, followed by definitive treatment of the diseased bowel after physiological and nutritional optimisation.

Start antibiotics covering enteric Gram negative organisms and anaerobes.

A practical adult regimen is:

Ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 12 hours.

For severe sepsis or substantial resistant organism risk:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.

Drain a well defined accessible abscess percutaneously.

Send aspirated material for culture.

Do not escalate corticosteroids or other immunosuppression into an uncontrolled undrained abscess.

After drainage, optimise nutrition and reassess the diseased bowel. Many patients with associated stenosis, fistula or medically refractory disease ultimately benefit from elective resection after sepsis has settled. Surgery approximately 2 to 4 weeks after successful drainage is often a useful window when recovery permits, although timing should remain individualised.

Operate urgently for generalised peritonitis, free perforation, failed drainage or persistent uncontrolled sepsis.

At definitive surgery, resect the responsible diseased segment rather than simply draining the abscess and leaving a severely stenosed or penetrating segment untreated.

Crohn Fistula

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management