HPI: This college student developed abdominal pain and bloody diarrhea in August of 2008. A diagnosis of ulcerative colitis was made and a number of theapies were tried (including prednisone and Remicaid). All were ineffective and he had a subtotal colectomy and ileostomy performed in December of 2008. Subsequent to that he continues to have some pain in the rectal stump and is scheduled for a J-pouch procedure in a few weeks. Three months ago, he developed painful draining tracts in the lower abdomen.
O/E: The patient is a healthy-appearing 23 yo man. The cutaneous findings are 5 - 10 mm in diameter sinus tracts with sero-sanguinous drainage. There are four active lesions at this time. The remainder of the cutaneous exam is negative.
Photos: (June 9, 2009)
Lab and Path: Nil
Diagnosis: Could this be an extra-intestinal manifestation of inflammatory bowel disease? This is more common with Crohn's disease than U.C. My working diagnosis is sinus tracts or abdomino-cutaneous fistulae. The patient was referred for the question of pyoderma gangrenosum. If this is P.g., it is a very atypical case.
Questions:
Has anyone seen and treated a similar patient?
He is scheduled to have a resection of the rectal stump with a re-anastamosis of small bowel to the rectum allowing closure of his ileostomy (I am not sure of exact procedure). Perhaps this will help. Your thoughts are appreciated.
I think the discharging sinus is probably not related to the underlying ulcerative colitis. The sinus track is along the surgical scar. This is usually due to infection. I would get a culture and treat the infection with the appropriate antibiotics and get the surgeon who operated on him to review. Henry Foong
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Since we know this is a “draining” fistula, I feel it is better to investigate the cause. There is after all an abnormal channel or tract that is leading to this continuous discharge for more than 3 months. My possible explanations are:
ReplyDelete1. Deep skin infection due to
(a) Retained surgical suture or foreign body since he has already undergone subtotal colectomy and ileostomy
(b) Localised deep seated abdominal or pelvic infections {as abscess is already being drained by the tract, the person does not necessary presents with constitutional symptoms of fever-pain etc}
(c) Non healing surgical wounds or secondary infection in a well healed scar
2. Neoplasm: It is always beneficial to rule out neoplasm of any kind in these chronic “non-healing” problems.
I feel it is best to investigate and demarcate the fistula sinus tracts. Sinography is the investigation of choice since it is a diagnostic imaging method involving opacification of a sinus tract, which may provide information that influences the choice of therapy. Concomitant CT scanning may lead to better delineation of the sinus tract. Sinography in association with fluoroscopy is also employed in evaluation. {http://www.mercycare.org/pdf/Fistula.pdf }
Shardul
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