Crohn病に起因したS状結腸子宮瘻の１例

抄録

　We report a case of a 74-years-old female with sigmoidouterine fistula and abdominouterine abscess as a complication of progressive Crohn's disease and treated successfully by a laparoscopic total hysterectomy. The patient was treated for Crohn's disease for over 20 years with oral and rectal mesalamine. Her disease was difficult to control because of recurrent multiple rectal ulcerations and subilius even under the treatments with various biologicals. The patient was admitted into our hospital with abdominal pain and fever. CT scan showed an abdominal abscess and colonoscopy found worsening of the ulcerations. Initially, she was treated conservatively with antibiotics and her symptoms improved temporarily, until she was found to have fecal vaginal discharge. MRI identified a fistula formation between the sigmoid colon and the left side of the uterus, and fecal material in the uterus. Repeated MRI following antibiotic treatments showed the persistent sigmoidouterine fistula and intrauterine abscess with fecal material. Total laparoscopic hysterectomy, bilateral adnexectomy, and sigmoid colon resection were performed following bilateral tubal ligations with LigaSure and cervical cerclage to prevent from intraabdominal leakage of the abscess and intrauterine fecal material. The patient was discharged on Day 14 postoperatively as she had an excellent recovery with no signs of recurrent infection. Pathology revealed endometriosis on uterine side and Crohn's disease on the other side of the fistula. In advanced Crohn's disease, fistulae may form with surrounding organs, but the fistula with the uterus is uncommon as it is an organ with thick muscular wall. Inflammatory bowel disease such as Crohn's disease has been increasing in recent years and may not be unusual in long standing, treatment resistant and complicated cases affecting female pelvic organs that require total hysterectomy. In addition to the collaboration with other departments, neo-surgical techniques should be devised to prevent from spreding intraperitoneal infection.