Coming full circle: an impressive case of Crohn's disease.

To cite: Westerveld D, Patel A, Drane W, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015214132 DESCRIPTION A young man in his 20s with a 1 -year history of Crohn’s disease, presented with severe abdominal pain, constipation, vomiting, 20 pound weight loss and 5–6 persistent watery stools per day. Three months prior to his presentation, the patient had received treatment with Humira, however, due to the loss of his job and lack of finances, he had not received subsequent treatment. Laboratory values were significant for an elevated C-reactive protein of 25 mg/L (0–4.9 mg/L), and an erythrocyte sedimentation rate of 16 mm/h. An abdominal/pelvic contrast-enhanced MRI enterography revealed multiple enteroenteric fistulas and distention of multiple loops of small bowel leading to compression of the stomach (figure 1). Subsequently, the patient underwent a laparoscopic ileocolectomy with ileo ascending colonic anastomosis, takedown of enteroenteric fistula and a stricturoplasty-type repair of the small bowel. Fistulising Crohn’s disease may cause significant morbidity and mortality if not treated effectively. Since the introduction of antitumor necrosis factor chimeric antibodies in the treatment of Crohn’s nearly 15 years ago by Derkx et al, biologics have gained an important place in the treatment of inflammatory bowel disease. Moreover, the ACCENT II trial demonstrated a higher rate of closure of fistulas in those treated with infliximab versus placebo. We present a case of a young man with significant enteroenteric fistulas leading to a closed loop of small bowel, bowel distention (figure 2) and compression of the stomach. With proper medical and surgical management, the patient’s symptoms improved and he is currently undergoing close medical follow-up.