Coloretroperitoneal Fistula of the Transverse Colon Caused by Crohn's Disease: A Case Report.

International Journal of Medical Science and Clinical Research Studies ISSN(print): 2767-8326, ISSN(online): 2767-8342 Volume 05 Issue 11 November 2025 Page No: 1938-1945 DOI: https://doi.org/10.47191/ijmscrs/v5-i11-24, Impact Factor: 8.188 1938 Volume 05 Issue 11 November 2025 Corresponding Author: Gerardo Bracamontes Patiño Coloretroperitoneal Fistula of The Transverse Colon Caused By Crohn's Disease: A Case Report Gerardo Bracamontes Patiño1, Alejandro Everardo Gasque2, Isidro Puerto Serrano3, María Fernanda Ibarra Guerrero4, Alexis Emir Noguera Echeverría5, Shadid Alejandra Rodríguez Gómez6 1Surgical Resident. Hospital General “Dr. Agustín O´Horán”. Facultad de Medicina de la Universidad Autónoma de Yucatán. 2Associate Physician and Adjunct Professor of the Postgraduate Program in General Surgery. Hospital General “Dr. Agustín O’Horán”. Facultad de Medicina de la Universidad Autónoma de Yucatán. 3Surgeon. Hospital General “Dr. Agustín O’Horán”. Facultad de Medicina de la Universidad Autónoma de Yucatán. 4Pediatrics Resident. Clínica Hospital Mérida, ISSSTE. Facultad de Medicina de la Universidad Autónoma de Yucatán. 5Surgical Resident. Clínica Hospital Mérida, ISSSTE. Facultad de Medicina de la Universidad Autónoma de Yucatán. 6Surgeon. Universidad Autónoma de Yucatán. ABSTRACT ARTICLE DETAILS Introduction: Crohn’s disease (CD) is an inflammatory bowel disease that can lead to severe complications such as fistulas. Colo-retroperitoneal fistulas are uncommon, and their origin in the transverse colon is exceptionally rare, representing a major diagnostic and therapeutic challenge. The aim of this report is to present a case of this atypical manifestation. Case Report: We present the case of a 15-year-old male patient with fever, weight loss, abdominal pain, and hematochezia. An abdominal CT scan confirmed the presence of a fistula connecting the transverse colon with the retroperitoneum, along with significant colonic stenosis. The diagnosis of CD was established through biopsy. Due to the severity of the condition, a total colectomy with end ileostomy was performed, achieving clinical remission (Harvey–Bradshaw Index ≤4). Discussion: This rare complication requires imaging studies such as computed tomography for diagnosis. Management is multidisciplinary, combining medical therapy with surgical intervention, which is reserved for complications or therapeutic failure. The goal of treatment is to control symptoms and achieve remission of this chronic disease. Conclusion: This case illustrates the challenges posed by an atypical presentation of CD. We conclude that individualized surgical management is essential and effective in resolving severe complications, representing a necessary therapeutic option to achieve remission and patient wellbeing. KEYWORDS: Crohn’s disease, colo-retroperitoneal fistula, transverse colon, colectomy, case report, complications. Published On: 30 November 2025 Available on: https://ijmscrs.com/ International Journal of Medical Science and Clinical Research Studies ISSN(print): 2767-8326, ISSN(online): 2767-8342 Volume 05 Issue 11 November 2025 Page No: 1938-1945 DOI: https://doi.org/10.47191/ijmscrs/v5-i11-24, Impact Factor: 8.188 1939 Volume 05 Issue 11 November 2025 Corresponding Author: Gerardo Bracamontes Patiño INTRODUCTION Crohn’s disease may present with a wide range of extraintestinal manifestations, including cutaneous symptoms such as metastatic Crohn’s disease, vulvar swelling, and genital edema [1–3]. In fact, in some cases, these cutaneous manifestations may precede the development of gastrointestinal symptoms [1–3]. Additionally, it has been reported that a significant proportion of patients with vulvar Crohn’s disease may display no gastrointestinal symptoms, making diagnosis challenging [4]. Likewise, it may affect any part of the digestive tract, from the mouth to the anus. Unlike ulcerative colitis, in Crohn’s colitis the rectum is affected in almost 40% of cases, with the ileocolic region being the most commonly affected site. In the involved intestinal segments, inflammation may be continuous; however, it is more likely for the inflammation to spare some regions, such that healthy areas of bowel are interposed between inflamed segments. The involvement in this disease is transmural, as it affects all layers of the mucosa. As inflammation, ulceration, abscesses, and fistulas resolve, fibrosis, submucosal thickening, and scarring ensue, leading to narrowing of intestinal segments, circumscribed stenosis, and partial or complete obstruction of the intestinal lumen [7]. With an etiology still unknown—similar to ulcerative colitis— Crohn’s disease is a complex, polygenic disorder in which diverse genetic and environmental factors are implicated. Various genetic polymorphisms have been associated with it, such as polymorphisms in the NOD2/CARD15 genes, which have been implicated in disease pathogenesis by conditioning an abnormal immune response to certain variations in the bacterial microflora [5]. Few studies have established associations with chronic diseases such as diabetes mellitus, hypertension, or infectious agents [6]. The onset of this disease is more frequent among patients 15 to 25 years of age, and the prevalence is similar in both genders. A second peak of incidence occurs between 50 and 70 years of age. It appears more frequently among the White population, and Jewish individuals are particularly susceptible. There is a higher incidence in northern Europe and the United States, as well as in industrialized regions compared with rural areas [6]. Incidence in Scandinavia and England is higher than in Germany and clearly greater than in Mediterranean countries such as France, Spain, Italy, or Greece. In the United States, a similar pattern is observed: incidence is higher in northern states such as Washington and Wisconsin compared with southern states such as Arizona, New Mexico, and Texas. Regions with the lowest incidence include Central America, South America, Japan, and Asia [7]. Prevalence can be estimated at approximately 10 to 20 times the incidence, and mortality does not differ from that of the general population. Its prevalence is estimated at 0.6 to 322 per 100,000 inhabitants in Europe, 0.88 to 67.9 per 100,000 in Asia and the Middle East, and 16.7 to 318.5 per 100,000 in North America [7]. In 2015, there were 9,953 cases of Crohn’s disease, with 1,097 hospitalizations and a hospitalization prevalence (hospitalized cases/100,000 inhabitants) of 0.54 for women and 0.50 for men. The average hospitalization rate per incoming patient (number of hospitalizations in one year/annual number of incoming patients) was 1.74. Throughout the year, 68 deaths were reported, with a mortality rate of 0.52 for women and 0.61 for men (mortality due to ICD-10: K50 per 100,000 people per year). Two peaks were noted in this report: among individuals ≥60 years (35.6%) and those 20–40 years (32.4%). Distribution of patients by severity and activity according to widely used assessment scales was as follows: among CD cases, 50.4% were classified as moderate to severe (Crohn’s Disease Activity Index), and 66.2% as moderately to markedly active (Harvey– Bradshaw Index) [8]. The gold standard for definitive diagnosis is histopathological analysis of endoscopic biopsy specimens. However, there are guiding tests such as pANCA determination, certain proinflammatory markers (CRP), complete blood count to identify the degree of anemia; serum proteins and albumin to assess nutritional status; colonoscopy to determine the extent of proximal involvement and search for differential features; as well as abdominal ultrasound and/or computed tomography. Stool cultures, wet mount for amoeba, and biopsy are useful for differential diagnosis of amebiasis, shigellosis, and Yersinia infections [6]. Among the complications of Crohn’s disease are transmural lesions, which predispose to the development of enteroenteric, enterocutaneous, and perianal fistulas, and in very rare cases, colo-retroperitoneal fistulas, which represent a diagnostic and therapeutic challenge, and whose management depends on their extent, associated symptoms, and inflammatory activity [9]. Among therapeutic options, the use of biologic agents such as anti-TNF therapies has been described in the literature [10]. Coloretroperitoneal Fistula of The Transverse Colon Caused By Crohn's Disease: A Case Report 1940 Volume 05 Issue 11 November 2025 Corresponding Author: Gerardo Bracamontes Patiño However, in complex cases, surgical intervention may be required to resect the affected segment [11]. CASE REPORT A 15-year-old male patient of Italian descent, height 163 cm and weight 40 kg, with a past medical history of juvenile rheumatoid arthritis diagnosed at 4 years of age, and no other known chronic or autoimmune diseases. He had a history of a retroperitoneal abscess (right psoas abscess of 200 ml) that required percutaneous drainage and antimicrobial therapy 2 months prior to the onset of the current clinical presentation. No known drug or food allergies. He presented to the emergency department with fever, asthenia, adynamia, hyporexia, weight loss, hematochezia, and abdominal pain. He reported that 2 weeks prior to hospital admission, a Penrose-type abdominal drain had been removed, and since its removal, there had been discharge of purulent exudate through the drain site, accompanied by intermittent fever up to 38.5°C, occurring up to three times daily. On physical examination, his vital signs were within normal limits, neurologically intact, and without cardiopulmonary compromise. Abdominal examination revealed an enterocutaneous fistula in the right flank with purulent exudate, surrounding erythematous skin, and increased temperature; the abdomen had present bowel sounds, was mildly distended and tympanic to percussion, without signs of peritoneal irritation. Upper and lower extremities were functional and without abnormalities. A fecal occult blood test was performed and resulted positive, as well as calprotectin and transferrin tests, which were positive as indicators of intestinal inflammation. Likewise, a contrastenhanced abdominal CT scan was performed 24 hours after hospital admission, with reconstructed images identifying a retroperitoneal abscess arising from the right psoas muscle measuring 7 × 4 cm and a fistula between the transverse colon and the retroperitoneum, in addition to transverse colon stenosis (Figures 1–2). Due to the presence of a retroperitoneal abscess, CT-guided percutaneous drainage was performed on day 7 of hospitalization, obtaining at least 100 cc of purulent material. Figure 1. Contrast-enhanced abdominal CT scan showing a colo-retroperitoneal fistula of the transverse colon (white arrow). Figure 2. Non-contrast and contrast-enhanced abdominal CT scan with image reconstruction showing stenosis of the transverse colon due to fibrosis (white arrow). Coloretroperitoneal Fistula of The Transverse Colon Caused By Crohn's Disease: A Case Report 1941 Volume 05 Issue 11 November 2025 Corresponding Author: Gerardo Bracamontes Patiño Given the unusual location of the colonic fistula, an InterferonGamma Release Assay (IGRA) was performed, which was negative, ruling out latent tuberculosis. A colonoscopy was performed on day 10 of hospitalization, reporting stenosis of the middle third of the transverse colon. Biopsies were taken for histopathological evaluation, which reported Crohn’s disease (Figures 3–5). Figure 3. Colonoscopy with biopsy sampling (black arrow). Figure 4. Middle third of the transverse colon with chronic inflammation. Figure 5. Stenosis of the middle third of the transverse colon preventing passage of the colonoscope. On day 22 of hospitalization, total colectomy plus end ileostomy was performed. Surgical findings included inflammation of the terminal ileum and the entire colon, a 10 mm cecal perforation communicating with the retroperitoneum, numerous inflamed mesenteric lymph nodes, as well as transverse colon stenosis with thickening of its walls and a colo-retroperitoneal fistula of the transverse colon in its middle portion and along its posterior border (Figures 6–7). Coloretroperitoneal Fistula of The Transverse Colon Caused By Crohn's Disease: A Case Report 1942 Volume 05 Issue 11 November 2025 Corresponding Author: Gerardo Bracamontes Patiño Figures 6–7. Surgical specimen of the transverse colon showing the orifice corresponding to the colo-retroperitoneal fistula. A new histopathological examination of the resected colon specimen was performed, again confirming the diagnosis of Crohn’s disease. According to the Lennard-Jones criteria, the patient met ≥3 criteria, and according to the Montreal Classification of Crohn’s Disease, he was categorized as A1, L2, B3. During the postoperative period, the patient remained on analgesic and antibiotic therapy, with monitoring of the ileal stoma, which demonstrated an adequate appearance, with no evidence of ischemia or mucocutaneous separation and with appropriate intestinal effluent. Therefore, hospital discharge was decided 8 days after the surgical intervention. Subsequently, three months after surgery, he developed jaundice due to cholestasis, which resolved with conservative medical management indicated by gastroenterology. He is currently under medical follow-up with a simplified Harvey– Bradshaw Index for Crohn’s disease ≤4, indicating remission. DISCUSSION Crohn’s disease is a chronic inflammatory bowel disease of multifactorial etiology, characterized by segmental transmural inflammation that can affect any part of the gastrointestinal tract [12]. Its development results from a complex interaction between genetic predisposition, intestinal dysbiosis, environmental factors, and the patient’s immune response [13]. Its clinical course is variable, with its main manifestations being abdominal pain, chronic diarrhea, weight loss, and fever, while its extraintestinal manifestations and complications include abscesses, stenosis, and fistulas [14]. Histologically, Crohn’s disease is characterized by transmural granulomatous inflammation, distinguishing it from ulcerative colitis. This same deep inflammation predisposes patients to the formation of fistulous tracts between intestinal structures or even toward adjacent organs [15]. In this report, we present the case of a 15-year-old patient who was brought for evaluation due to fever, hematochezia, abdominal pain, hyporexia, and weight loss, with physical examination revealing an enterocutaneous fistula in the right flank. A contrast-enhanced abdominal CT scan with image reconstruction identified a fistula between the transverse colon and the retroperitoneum, as well as transverse colon stenosis. Therefore, endoscopy with biopsy sampling was performed, which confirmed Crohn’s disease. Colo-retroperitoneal fistulas, such as the one documented in this case, correspond to abnormal tracts that communicate the colon—usually the descending or sigmoid segment—with the Coloretroperitoneal Fistula of The Transverse Colon Caused By Crohn's Disease: A Case Report 1943 Volume 05 Issue 11 November 2025 Corresponding Author: Gerardo Bracamontes Patiño retroperitoneal space. These originate as a consequence of severe transmural inflammatory processes characteristic of Crohn’s disease that extend into deeper planes [16]. In our case, the anatomical complexity is even greater, given that the fistula originated from the transverse colon, a less common site for this type of pathological communication. The clinical presentation of this complication may be insidious, with symptoms such as abdominal or lumbar pain, fever of unknown origin, weight loss, and general malaise. In severe cases, symptoms may be associated with abscesses, retroperitoneal empyema, or urinary symptoms due to extension toward neighboring structures [17]. Diagnosis requires contrast-enhanced abdominal CT to identify the fistulous tract and any associated collection. Management must be individualized, with surgical intervention required in complex cases [18]. The presence of retroperitoneal fistulas is associated with increased morbidity and typically requires a multidisciplinary approach combining medical treatment (anti-TNF biologics) and, frequently, surgical intervention for abscess drainage and resection of affected segments, avoiding anastomosis in the presence of active inflammation or free pus [19–22]. The prevalence of retroperitoneal fistulas in Crohn’s disease is low, as these are uncommon complications compared with other types of fistulas [23]. Surgical treatment of Crohn’s disease is reserved for complications such as obstructions, abscesses, or fistulas, and may include intestinal resection or fistula management; however, the main goal remains disease control and remission [24]. Surgical treatment is indicated in cases of failure of medical therapy, presence of complications (abscesses, sepsis, obstruction, significant malabsorption, recurrent infections), or when a fistula causes severe symptoms or deterioration of the patient’s general condition [25–27]. Surgery usually involves resection of the diseased intestinal segment and primary closure or repair of the secondary affected organ or structure, preserving healthy intestine whenever possible [25, 27]. The decision regarding the extent of resection and the need for additional procedures depends on the location and involvement of adjacent organs. The presence of abscesses must be treated beforehand through percutaneous or surgical drainage prior to initiating immunosuppression or definitive surgery [27]. Optimal management of retroperitoneal fistulas in Crohn’s disease requires multidisciplinary evaluation with advanced imaging (ideally magnetic resonance imaging or computed tomography) to define fistula anatomy and extent [28]; initiation of biologic therapy (anti-TNF agents as first-line) to induce remission and, if possible, avoid surgery [29]; and surgical intervention in the presence of complications, as in our case, in which the patient presented to the emergency department with a colo-retroperitoneal fistula requiring total colectomy and terminal ileostomy [25–27]. Furthermore, current literature suggests that in the presence of intraabdominal abscesses, these should be drained prior to initiating immunosuppression or surgery [25]. Treatment of Crohn’s disease depends on disease severity and extent and may include immunosuppressive medications, dietary and lifestyle modifications, and, in some cases, surgery. Although treatment can help control symptoms and prevent complications, Crohn’s disease is a chronic condition with no cure and can significantly impact patients’ quality of life [30]. The principal goal of treatment is to achieve clinical remission, manifested by a decrease in the number of diarrheal stools, absence of rectal bleeding, fistula healing, resolution of extraintestinal manifestations, and improvement in laboratory parameters. Other treatment goals include preventing relapses, maintaining remission with the lowest possible dose of steroids, avoiding complications, surgeries, and hospitalizations, improving quality of life, and preventing mortality due to the disease or its treatment [31]. CONCLUSION The colo-retroperitoneal fistula originating from the transverse colon is an exceptionally rare complication of Crohn’s disease, and this case in a 15-year-old patient illustrates the challenges posed by an atypical presentation. The presence of stenosis and fistulization to an uncommon anatomical site presented significant diagnostic and therapeutic difficulties that ultimately required complex surgical management, including total colectomy with terminal ileostomy. Although surgical treatment may be controversial, this case demonstrates that an individualized approach is essential and that surgery is a necessary and effective therapeutic option to resolve severe complications, achieving disease remission and the patient’s overall well-being. ETHICAL CONSIDERATIONS Informed consent was obtained from the patient’s legal guardian for publication of this case and accompanying images. This case report required institutional review board approval. CONFLICT OF INTEREST The authors declare no conflict of interest. ACKNOWLEDGMENTS Special acknowledgment is given to the patient’s mother, who wishes to remain anonymous, for her assistance in providing detailed information regarding the patient’s clinical history and background. We also extend our gratitude to the authors for their direct and indirect contributions to this manuscript. 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