• 12 Years old girl underwent open appendectomy for appendicular perforation on 25-may-2020.
• She was apparently asymptomatic till June 2020 when she followed up with complaints of opening up of previous incision wound with pus discharge.
• She was treated conservatively with antibiotics according to pus culture sensitivity report .
• Since then her wound hasn’t healed and she is having persistent discharge.
Wound dehiscence in June 2020.
• She was evaluated in December 2020.
• Colonoscopy was done – showed ulceration with nodularity of IC junction , with narrowing ulceration at IC junction. Scope couldn't be passed into terminal ileum.
• Biopsy slides were reviewed here.
• IC biopsy- suggestive of mild active inflammation. Mild cryptitis, no evidence of parasites , granulomas, dysplasias, malignancy.
• Gene Xpert and Rapid TB culture done on colonoscopic biopsy, did not show any M. Tb growth.
• Appendectomy slide review- suggestive of granulomatous appendicitis. No necrosis was seen.
MR enterogram (December 2020)
• Contracted and deformed Cecum with adjacent mural thickening ectending into the terminal ileum.
• Significant luminal narrowing with evidence of enterocutaneous fistula opening into right iliac fossa lateral wall.
• Puckering of the overlying skin suggestive of chronic fistula.
• Few subcentric lymphnodes noted in the RIF.
MR enterogram (December 2020)
• Came to AIG for further evaluation.
• Only symptoms – occasional pain in abdomen on/off, crampy in nature and perisistent discharge from the wound.
• Routine investigations were done.
• Mountoux test done in January 2020 was negative.
• TB quantiferon gold done on January 2020 was negative.
• LFT, RFT, were unremarkable.
• Hb- 11gm/dl , serum iron – 35mcg/dl.
• ESR – 28mm/hr.
• Fecal calprotectin – 75mg/kg.
Present status of wound and discharge.
Summary
• 12 years old girl,
• Status post appendectomy on may 2020,
• Persistent enterocutaneous fistula since June 2020.
• Next plan of management ??
Based on history, colonoscopy and biopsy findings, it is a case of fistulizing Crohn's disease. This has to be managed with biologics -anti TNF. If fistula persist even after healing of ulcers over IC valve and narrowing persist, than proceed with IC valve dilation to relieve upstream pressure.