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Vedolizumab in Crohn’s disease with rectal fistulas and presacral abscess: A case report

BACKGROUND Fistula and intraabdominal fistula are common complications of Crohn’s disease (CD), but complex rectal fistula with abscess formation is rare. Tumor necrosis factor antagonists combined with percutaneous drainage or surgical intervention is optimal treatment for fistulizing CD with intraabdominal abscess. There is no study show the efficacy of vedolizumab in such complicated condition. CASE SUMMARY A 47-year-old man has decompensated liver cirrhosis, child B. He suffered from abdominal pain, bloody diarrhea, fever, and body weight loss. CD with rectoprostatic fistula, rectopresacral fistula, pre-sacral abscess and cyto-megalovirus (CMV) infection were noted. He received antibiotics, anti-viral therapy, transverse colostomy and vedolizumab treatment. Six months later, he had deep remission and complete fistula tracts closure. CONCLUSION Early vedolizumab and stool diversion are effective and safe in treating CD with complex rectal fistula with abscess formation.


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INTRODUCTION
Fistula affects up to 50% Crohn's disease (CD) patients within 20 years of initial diagnosis [1,2] . It includes perianal, rectovaginal, enterocutaneous and internal fistula, but no rectoprostatic fistula or rectopresacral fistula were reported. The treatment of fistula usually requires a combination of medical and surgical approach [3] . As far as medical treatment is concerned, tumor necrosis factor (TNF) antagonists are most effective to treat fistulizing CD [4] . However, some studies also noted the beneficial effect of vedolizumab for fistulizing CD [5,6] . We presented the patient of CD, complicated with rectoprostatic fistula, rectopresacral fistula and presacral abscess. He had complete fistula closure and deep remission after transverse colostomy and vedolizumab treatment for six months.

Chief complaints
Low abdominal pain and intermittent bloody stool for 6 mo.

History of present illness
A 47-year-old man has decompensated liver cirrhosis, child B, hepatitis C virus (HCV) and alcoholism related, complicated with hypoalbuminemia, hyperbilirubinemia, coagulopathy, thrombocytopenia, splenomegaly and esophageal varices, Form 1. He complained low abdominal pain and intermittent bloody stool for 6 mo. Appendicitis was diagnosed in local hospital, and he received appendectomy on 16 th November 2019. However, he suffered from progressive low abdominal pain, bloody stool, dizziness, and intermittent fever up to 38 °C for four days. He also mentioned body weight loss 20 kg within one year. He was brought to our emergent department. February 7, 2021 Volume 27 Issue 5

History of past illness
Decompensated liver cirrhosis, child B, hepatitis C virus infection and alcoholism.

Personal and family history
Appendicitis was diagnosed in local hospital, and he received appendectomy on 16 th November 2019.

Laboratory examinations
Lab data revealed hemoglobin 10.

FINAL DIAGNOSIS
He was diagnosed to have CD and CMV colitis by endoscopy and pathological findings. The CD activity index (CDAI) was 526 points and Harvey-Bradshaw index (HBI) was 22 points. He also had rectoprostatic fistula, rectopresacral fistula and presacral abscess diagnosed by MRI findings.

TREATMENT
He refused percutaneous abscess fine needle aspiration, and we kept Tazocin for abscess treatment for 27 d. Because of positive CMV IHC staining result, he also received intravenous ganciclovir for 17 d and then valganciclovir po treatment for two months. Transverse colostomy was performed for stool diversion on 25 th December 2019. He couldn't tolerant azathioprine due to pancytopenia and vedolizumab (300 mg 8 wk) was prescript since 22 th January 2020.

OUTCOME AND FOLLOW-UP
Follow-up sigmoidoscopy showed mucosal healing without any fistula tract ( Figure 1D) on 9 th July 2020. The pathologist reported minimal inflammatory activity ( Figure 3C). Lower gastrointestinal series mentioned no more fistula tract (Figure 4) on 21 th July 2020. There was no more rectoprostatic or rectopresacral fistula ( Figure 5A) and pre-sacral abscess ( Figure 5B) in MRI. After vedolizumab treatment for 6 mo, the CDAI was 42 points and HBI score was 0 point. His body weight body also increased 20 kg, back to the same level before the episode.

DISCUSSION
Fistulizing CD results in not only high morbidity but also impaired health-related quality of life [4] . Biologics combined with surgical intervention seems to be the best February 7, 2021 Volume 27 Issue 5 resolution. Although Infliximab has strongest evidence in fistulizing CD treatment [7,8] , vedolizumab also showed its efficacy in some studies [5,6] . However, vedolizumab has better safety profiles (less severe adverse events and infections) in real world studies [9,10] . Intra-abdominal abscess occurs in up to 20% of patients with CD [11,12] . Adequate percutaneous drainage combined with early adalimumab treatment achieves up to 74% successful rate [13] . In this case, it was difficult to drain the presacral abscess and patient refused, too. Therefore, we chose vedolizumab with transverse colostomy in treating the complex rectal fistula and presacral abscess without abscess drainage.
This patient received vedolizumab treatment one month after confirmed the diagnosis. Earlier initiation of biological treatment shortly after diagnosis (less than one year) in patients with moderately to severely active CD leads to improved longterm clinical outcomes [14] . Besides, early stool diversion with transverse colectomy and early anti-viral treatment for CMV infection were crucial to achieve the good outcome in this case.

CONCLUSION
Vedolizumab with loop transverse colostomy was effective in treating CD with complex rectal fistulas with pre-sacral abscess. Besides, early biological and anti-CMV treatments might also lead to the favorable outcome. February 7, 2021 Volume 27 Issue 5