A 23-year-old woman with a 4-year history of ileo-colonic Crohn's disease comes to the physician complaining of gas and a feculent vaginal discharge for the past 2 weeks. She has no fever, chills, abdominal pain, nausea, or vomiting. She has been treated with azathioprine for her Crohn's disease without any recent flares. Her medications include vitamin D and vitamin B12 supplements.
Her blood pressure is 100/60 mm Hg, pulse is 72/min, and respirations are 14/min. Examination shows a soft and nontender abdomen without hepatosplenomegaly. Rectal examination is within normal limits. Pelvic examination is unremarkable.
Laboratory results are as follows:

Magnetic resonance imaging of the pelvis shows a fistulous tract from the rectum through the vaginal wall with surrounding wall edema.
Which of the following is the most appropriate next step in management?

Question

A 23-year-old woman with a 4-year history of ileo-colonic Crohn's disease comes to the physician complaining of gas and a feculent vaginal discharge for the past 2 weeks.  She has no fever, chills, abdominal pain, nausea, or vomiting.  She has been treated with azathioprine for her Crohn's disease without any recent flares.  Her medications include vitamin D and vitamin B12 supplements.
Her blood pressure is 100/60 mm Hg, pulse is 72/min, and respirations are 14/min.  Examination shows a soft and nontender abdomen without hepatosplenomegaly.  Rectal examination is within normal limits.  Pelvic examination is unremarkable.
Laboratory results are as follows:

Magnetic resonance imaging of the pelvis shows a fistulous tract from the rectum through the vaginal wall with surrounding wall edema.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_9807_ac63_853d_d7f5336fbdca_MD0002_00 Approximately 20%-30% of patients with Crohn's disease develop anorectal fistulas. About half of these patients present with perianal fistula at the time of diagnosis. Rectovaginal fistulas usually present with vaginal fecal discharge, increased vaginal gas, or severe malodorous discharge. Patients with asymptomatic fistulas do not require therapy as the majority remain asymptomatic or heal spontaneously. Rectovaginal fistulas not related to inflammatory bowel disease (IBD) are treated only with surgery. IBD-related fistulas are first treated medically and repaired surgically only if medical therapy fails. Patients with mild symptoms can be treated with oral antibiotics (metronidazole plus ciprofloxacin). However, the treatment often requires a prolonged period (6-12 months) with gradual tapering due to the risk of relapse. Moderate to severe symptoms usually require immunomodulator therapy (eg, anti-TNF inhibitors, thiopurines, or tacrolimus). Anti-TNF inhibitors (eg, infliximab and adalimumab) have the best evidence for both short-term healing and long-term management of rectovaginal closure. Thiopurines and azathioprine/6-mercatopurine are also effective in some patients. Calcineurin inhibitors (eg, cyclosporine and tacrolimus) are effective but reserved as last-line therapy due to significant toxicity and side effects. Surgery is usually reserved for patients who fail medical therapy or develop recurrent fistulas requiring long-term closure (Choice E). (Choices B and D) Prednisone and 5-ASA compounds (eg, mesalamine) are effective for many other gastrointestinal symptoms of IBD but are not as effective for treating rectovaginal fistulas. In addition, this patient has no other active symptoms of Crohn's disease. Educational objective: Rectovaginal fistulas should be suspected in Crohn's disease patients complaining of vaginal fecal discharge, increased vaginal gas, or severe malodorous discharge. Initial medical therapy consists of antibiotics for mild symptoms and anti-TNF inhibitors for moderate to severe symptoms. Surgery is usually reserved for patients who fail medical therapy or develop recurrent fistulas. __________ References: Current treatment of rectovaginal fistula in Crohn's disease. (http://www.ncbi.nlm.nih.gov/pubmed/21448347) Infliximab for the treatment of fistulas in patients with Crohn's disease. (http://www.ncbi.nlm.nih.gov/pubmed/10228190) Infliximab maintenance therapy for fistulizing Crohn's disease. (http://www.ncbi.nlm.nih.gov/pubmed/14985485)

A 23-Year-Old Woman with a 4-Year History of Ileo-Colonic Crohn's