Crohn's disease of the appendix with enterocutaneous fistula post-appendicectomy: An approach to management

CONTEXT: Isolated involvement of the appendix in Crohn's disease is reported to be 0.2% to 1.8%, and is usually associated with ileocaecal Crohn's disease in 25% of ileal and 50% of caecal disease. While appendicitis in a patient who was previously diagnosed to have ileocaecal Crohn's may be managed with appendicectomy and ileocaecal resection, appendicectomy alone when performed for appendicitis in a patient with unsuspected ileocaecal Crohn's disease could lead to postoperative complications including enterocutaneous fistula. CASE REPORT: A young female patient who underwent appendicectomy elsewhere for acute appendicitis presented to us with a persistent enterocutaneous fistula of 6 weeks duration. She had complained of general ill health and occasional altered bowel habits for 6 months prior to the acute appendicitis presentation. Our investigations, including a CT scan, suggested the possibility of ileocaecal Crohn's disease. She underwent excision of the enterocutaneous fistula and ileocaecal resection, and histopathology of the resected specimen confirmed Crohn's disease. In the postoperative period she received mesasalazine. When last seen 2 years later during her regular follow-up, she was found to be in good health. CONCLUSION: The possibility of ileocaecal Crohn's disease should be considered in patients presenting with unexplained postoperative enterocutaneous fistula following appendicectomy. A high index of clinical suspicion is required to make a prompt diagnosis and institute appropriate further treatment in form of ileocaecal resection.