2054 Crohn’s Colitis Creeping Into a Colonic Conduit

INTRODUCTION: Crohn’s disease is an inflammatory bowel disease (IBD) that can affect any part of the digestive tract and may present with diarrhea, abdominal pain, and/or weight loss. A subset of patients with Crohn's disease are asymptomatic and are diagnosed endoscopically before the onset of symptoms. Here, we report an unusual presentation of Crohn’s disease which was diagnosed following postoperative complications from a sleeve gastrectomy. CASE DESCRIPTION/METHODS: A 46-year-old obese but otherwise healthy female underwent an elective laparoscopic sleeve gastrectomy for weight loss. She had an uneventful perioperative course, however returned one week post op with severe abdominal pain and was found to have staple line dehiscence, esophageal leak and mediastinal fistula requiring multiple repairs, including a failed roux-en-Y esophagojejunostomy and eventually required gastrectomy with esophageal stump. She was transferred to our facility for surgical consultation and underwent right thoracotomy for persistent esophageal leak requiring esophagostomy revision and creation of a spit fistula. Given esophageal discontinuity, a reconstruction with colonic interposition was suggested. In preparation, the patient underwent a colonoscopy with surprising findings of cecal, proximal ascending, and distal sigmoid colonic inflammation [Figure 1]. Biopsies revealed chronic active colitis with cryptitis, suggestive of Crohn’s disease. She denied any symptoms preoperatively and has no family history of IBD. Labs showed elevated calprotectin at 222 ug/g and mild leukocytosis. Magnetic resonance enterography was unremarkable. She was started on Infliximab 5 mg/kg at 0, 2, 6, then every 8 weeks with normalization of calprotectin after 3 doses. She eventually underwent takedown of her spit fistula and jejunal interposition to re-establish esophageal continuity [Figure 2]. DISCUSSION: This case raises the question of whether the postoperative complication was caused by underlying upper gastrointestinal tract Crohn’s disease. Conversely, it is possible the patient’s numerous gastrointestinal procedures triggered colonic mucosal disease in this susceptible individual. Although this presentation is rare, if similar presentations occur in the future, we may need to consider a role for either preoperative endoscopy or screening with inflammatory markers prior to elective bariatric procedures as this diagnosis could have potentially harmful consequences in the post-operative period.