The constant search for new therapeutic options and the possible adverse effects of long-term use of some therapies in Crohn’s disease make it an issue that is still eagerly discussed among gastroenterologists. The role of surgery in treating this disorder is also constantly discussed. Is there still a place for the surgical approach in the era of biological treatment? Is it reserved for abscesses, fistulas and strictures? Is CD always surgically treated in designated accreditation units?

In this paper, we present a case of a patient admitted to a district hospital at a time point when it was too late to initiate biological treatment without prior surgical intervention. We also discuss the key therapeutic principles, emphasising that it is not always possible to follow generally accepted standards.

Crohn’s disease (CD), along with ulcerative colitis (UC), belongs to the group of inflammatory bowel diseases (IBDs). IBDs are the second most common group of autoimmune disorders after rheumatoid arthritis (RA) (1). Although the pathogenesis of CD is still under investigation, it is currently assumed that multiple genetic factors, as well as environmental and individual aspects are involved. CD is a full-thickness inflammation of the bowel wall that can involve any part of the gastrointestinal (GI) tract, from the vestibule to the anus. Terminal ileum is the most commonly affected area, as also described in the presented case. Inflammatory lesions are described as granulomatous and non-caerating. These lesions are not continuous as in the case of ulcerative colitis (UC), but form microscopically inflamed sections separated by macroscopically normal appearing mucosa (skip areas). Endoscopically, a ‘cobblestone’ appearance of the mucosal surface is usually described. The most common clinical manifestations include abdominal pain (up to 90% of patients) and diarrhea (bloody or not). Treatment delay may result in malnutrition, hypoalbuminaemia, oedema, and complications involving other organs. Despite diagnostic advances and the increasing awareness among doctors, hospitalisation rates due to complications of the underlying disease, such as (sub)obstruction, external or internal fistulas, and abscesses, are still high. The case we describe shows that there is still too little vigilance among doctors for IBDs in diagnostically and therapeutically challenging patients. Thorough diagnosis and treatment will be discussed in more detail later in this article.

A 30-year-old male patient living in the USA was admitted to hospital after almost 4 months of treatment for perineal and perianal phlegmon in the USA. According to patient-reported medical history (unavailable medical records and data on previous treatment), the man was treated by a primary care physician due to a perianal lesion, possibly an abscess, by repeated thick-needle punctures and evacuation of abscess contents. This, however, brought only minimal improvement. He did not receive any medications and no diagnostic workup was performed. There was only minor and temporary improvement in the local condition. The patient was admitted to the hospital in a moderate general condition, due to the symptoms of massive perineal and perianal phlegmon. Rectal examination on admission, which was very painful for the patient, revealed a large, boggy mass in the anterior rectal wall. Bilateral perianal pus-discharging wounds after previous incisions were found. The patient was put on empiric intravenous antibiotic therapy (Metronidazole 500 mg every 8 hours, Biotrakson 1 g every 12 hours) and scheduled for surgery. The ischiorectal abscess was incised and drained to evacuate the purulent contents. The abscess cavity was thoroughly rinsed. The drain was maintained. Due to the lack of expected improvement after 3 days, the patient was qualified for a revision of the site after the incision of perineal phlegmon in an operating setting. The applied anesthesia allowed for a thorough examination of the patient, during which, three fistulous tracts were revealed by methylene blue solution administered into the incisions. The local and general condition as well as the treatment course raised the suspicion of inflammatory bowel disease. Azathioprine, mesalazine and hydrocortisone were included. Due to anaemisation up to 6.7 g/dL (starting Hb 10.0 g/dL), 3 units of packed red blood cells (PRBCs) were ordered for the patient. On the day of surgery, 1 unit of PRBC was transfused. In the following days, 2 more units were administered (the method of PRBC administration was due to the deficit of the preparation at the blood donation station). Haemoglobin levels increased to 9.7 g/dL. The patient was qualified for colonoscopy. During prep, another drop in haemoglobin (6.6 gL/dL) occurred. Therefore, it was decided to administer another 2 units of PRBC.

A colonoscope was inserted into the final segment of the small intestine, showing the appendix opening and the Bauhin’s valve. Distinct inflammatory lesions with flat ulcers and pseudopolyps were found in the terminal ileum. Samples were collected for histopathology. Bloody content in the small intestine was also detected. Multiple ulcers with islands of normal appearing intestinal mucosa in between (“cobblestone appearance”) were found in the large bowel. Histopathological samples were also collected from ulcers. After PRBC transfusion, the haemoglobin level was 8.5 g/dL. After endoscopic confirmation of the diagnosis of Crohn’s disease, numerous attempts were made to transfer the patient to a unit with a higher reference level. This, however, was unsuccessful due to the Christmas and New Year period. Further deterioration of the patient’s general condition was observed, with progressing anaemisation (haemoglobin decreased to 6.4 g/dL). Due to the deteriorating general condition, the inability to perform further transfusions and control the GI bleeding, as well as impossible transfer to a reference centre, the patient was qualified and agreed for surgery. Intraoperatively, a small amount of peritoneal fluid was found, the small intestine from the Treitz ligament appeared macroscopically normal, with dark, possibly bloody content in some of its sections. The final section, approx. 10 cm before the Bauhin valve, had a thickened, bloodshot, inflamed wall, with multiple hard adhesions, e.g. with the sigmoid colon, forming a lumpy conglomerate over the length of approx. 30 cm. Just at the Bauhin valve, the final section of 5-7 cm appeared macroscopically normal. A decision was made to resect the final, inflamed segment of the ileum (approx. 40 cm of the intestine) by performing Hartmann’s procedure and preserving the cecum. During isolation of adhesions and separation of the small intestinal conglomerate from the large bowel, a small fistula to the sigmoid colon was found. The fistulous opening of about 4 mm in the sigmoid was closed with two levels of sutures.