1.To discuss the indications and common presentations of internal gastrointestinal fistulas in Crohn's disease
2.To describe the tests used to confirm the presence of internal fistulas in Crohn’s disease
3.To discuss surgical techniques used to manage internal fistulas in Crohn’s disease
1. A 23-year-old female comes to your office with newly diagnosed terminal ileal Crohn’s disease. What is her chance of developing a fistula in her lifetime?
2. A 35-year-old male with a 5-year history of Crohn’s disease is admitted to the hospital with right lower quadrant abdominal pain, recent onset of diarrhea and a 10-pound weight loss. You suspect an entero-colic fistula. What would be the most specific test to confirm this diagnosis?
A. Gastrograffin enema
C. CT colonography
D. MR enterography
3. A 46-year-old female with history of Crohn’s disease with a history of abdominal pain and diarrhea presents with a work-up that included a CT enterography which demonstrated an ileo-sigmoid fistula and a colonoscopy which did not reveal any active sigmoid colitis or stricture. On operative exploration, an ileocolic fistula is noted to be on the anti-mesenteric side with a normal appearing sigmoid colon. After ileal resection is completed, the best way to manage the sigmoid fistula is:
A. Debridement and over-sewing
B. Sigmoid wedge resection and end to end anastomosis
C. Sigmoid resection with side to side anastomosis
D. Sigmoid colectomy with colostomy
4. A 37-year-old male with Crohn’s disease was noted to have an entero-enteric fistula on an MR enterography. He has no abdominal pain or diarrhea. Which of the following statements is true in the management of Crohn’s entero-enteric fistulae?
A. Entero-enteric fistulae are always associated with symptoms of diarrhea and malabsorption
B. Entero-enteric fistulas can be addressed by medical management
C. Entero-enteric fistulae routinely require surgical intervention
D. Anti TNF-alpha agents are effective in achieving closure on entero-enteric fistulae
5. A 29-year-old male with history of Crohn’s disease was admitted to the hospital with urosepsis. CT scan of the abdomen/pelvis performed on admission shows a phlegmon involving the terminal ileum and the bladder. After his urosepsis resolves he is placed on a trial of anti-TNF alpha therapy, but a fistula persists. Surgical management of this fistula involves which of the following steps?
A. Resection of bowel with debridement and closure of bladder defect and postoperative foley decompression
B. En-bloc resection of involved bowel and bladder with closure
C. Resection of bowel with debridement and closure of bladder defect decompression with suprapubic cystostomy tube
D. Resection of bowel without closure of bladder defect and decompression of bladder with a foley
6. A 67-year-old male with history of Crohn’s disease with previous ileo-colic resection develops right upper quadrant abdominal pain, weight loss and diarrhea. You suspect an ileo-duodenal fistula. The best test to establish this diagnosis is
B. Upper GI series
C. Barium enema
D. Deep enteroscopy
7. A 34-year-old with ileo-duodenal fistula undergoes resection. A fistula is noted from the anastomosis to the third portion of the duodenum without significant duodenitis. Which one of the following can help decrease re-fistulization?
A. Hand sewn instead of stapled ileocolic anastomosis
B. Omental pedicle flap distancing anastomosis from the duodenum
C. Cessation of biologic agents post operatively
D. Surgical drain placement
8. A 45 year old male with long standing Crohn’s disease presents with abdominal pain, weight loss, feculent belching and emesis for last 6 months. A barium enema shows gastrocolic fistula. Intra-operatively you note a 1cm fistula between inflamed transverse colon and the antrum of the stomach with a relatively non-inflamed stomach. The best way to manage the gastric side of the fistula is
A. Graham patch closure
B. Debridement and primary repair
C. Bilroth 1 reconstuction
D. Roux-en-y gastrojejunostomy
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