Description

A 62-year-old male smoker was diagnosed with ileo-colonic Crohn's disease 1 year previously, which was complicated by an asymptomatic terminal ileal stricture diagnosed on contrast radiology. Clinical and biochemical remission were induced initially by steroids and then maintained by mesalazine (1 g three times a day) and azathioprine (2 mg/kg daily). Six months following diagnosis, the patient complained of recurrent urinary tract infections and haematuria, and was found to have raised inflammatory markers, hypoalbuminaemia and anaemia. CT scan of the abdomen showed an internal fistula (figure 1, arrow) with calcification, between a thickened terminal ileum and the right posterior bladder wall. A small gas bubble was seen in the bladder (figure 2, arrow). Surgical excision of the terminal ileum, closure of the fistula and enterocolic anastomosis was thus carried out. Histology of the resected specimen showed active Crohn's disease. Following surgery, he resumed azathioprine (2.5 mg/kg daily) and soon after was started on infliximab therapy. He has since remained in remission.

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Figure 1

Internal fistula connecting the terminal ileum with the right posterior bladder wall.

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Figure 2

Small gas bubble within the bladder.

Enterovesical fistula is a well-known recognised complication of terminal ileal Crohn's disease and may occur at any age and at any stage of the disease.1 Fistulating terminal ileal Crohn's disease preferentially involves the bladder, given the close anatomical relationship between these two structures. A high level of suspicion should be maintained and due attention given, when symptoms such as pneumaturia (often the first clinical symptom), recurrent urinary tract infections or fecaluria are reported by Crohn's patients. CT of the abdomen is a sensitive and non-invasive method of detecting this complication.2