Mercadal Nuria Rosa, Wiebke Eric A
Department of Surgery, Indiana University School of Medicine, Indianapolis IN, USA.
Ann Gastroenterol. 2012;25(4):361-364.
We report a rare case of right-sided colobronchial fistula in a 47-year-old, severely malnourished male with a history of regional enteritis and recurrent right lower and middle lobe pneumonias medically managed with the addition of the immunomodulator infliximab prior to surgery. On admission, evaluation of sputum cultures and chest radiograph pattern of pneumonia led to the suspicion of colobronchial fistula. This diagnosis was confirmed by abdominal CT enteroclysis. This patient's pneumonia was initially treated with empiric antibiotics, then focused antibiotics based on culture results. The treatment for the regional enteritis and the secondary colobronchial fistula consisted of immunosuppression with infliximab, bowel rest, and total parenteral nutrition. The patient was discharged on a limited course of prednisone and received maintenance therapy with 3mg/kg IV infliximab infusions for four additional treatments with dramatic improvement in his clinical condition. Surgical therapy consisted of only bowel resection; no thoracic surgery or lung resection was necessary. The patient has had a dramatic improvement in his clinical condition and is currently disease-free on no maintenance therapy. The use of TNF-blocking agents such as infliximab may simplify the surgical approach in patients with complicated fistulous Crohn's disease.
我们报告了一例罕见的右侧结肠支气管瘘病例，患者为一名47岁的严重营养不良男性，有局限性肠炎病史，右下叶和中叶反复发生肺炎，术前在药物治疗中加用了免疫调节剂英夫利昔单抗。入院时，通过对痰培养和肺炎的胸部X线片表现进行评估，怀疑存在结肠支气管瘘。腹部CT小肠灌肠造影证实了这一诊断。该患者的肺炎最初采用经验性抗生素治疗，然后根据培养结果使用针对性抗生素。局限性肠炎和继发性结肠支气管瘘的治疗包括使用英夫利昔单抗进行免疫抑制、肠道休息和全胃肠外营养。患者出院时接受了有限疗程的泼尼松治疗，并接受了3mg/kg静脉注射英夫利昔单抗的维持治疗，额外进行了四次治疗，临床状况有显著改善。手术治疗仅包括肠切除术；无需进行胸外科手术或肺切除术。患者的临床状况有了显著改善，目前无需维持治疗，疾病无复发。使用英夫利昔单抗等肿瘤坏死因子阻断剂可能会简化复杂性瘘管型克罗恩病患者的手术方法。
