Crohn’s Colitis with Perianal Disease Complicated by Collagenous Colitis: Discourse on Management Options

disease. She also had a history of depression and had undergone trials of several mood stabilizers over the years. The patient was being maintained in clinical remission on a TNF blocker when she developed new onset perianal pain with discharge as well as increased diarrhea for which endoscopic and surgical evaluation was scheduled. An active perianal fistula was confirmed with a probe ( fig. 1 ). Flexible sigmoidoscopy performed after seton placement into the fistula revealed a completely normal colonic mucosa to the level of the splenic flexure except for a minute area of inflammation at the anorectal junction where biopsies were taken. The pathology report suggested evidence of subepithelial accentuation of collagen band with increased chronic inflammation ( fig. 2 a, b). A subsequent colonoscopy performed for complete colonic mucosal evaluation also did not reveal any endoscopic disease, however, random colonic biopsies taken during the procedure confirmed the subepithelial accentuation of collagen band with increased chronic inflammation throughout the colon, therefore establishing a diagnosis of concomitant CC in the patient ( fig. 3 ). The patient had a history of severe acute steroid psychosis in the past and Dear Sir, Crohn’s disease (CD) and collagenous colitis (CC) are rarely seen together in clinical practice and when they are, they may present a management challenge. We describe the case of a patient with perianal CD unable to take steroids whose clinical course was complicated by the development of CC. A brief review of the topic follows the case presentation.