The patient was a 40-year-old female, initially diagnosed as UC (total colitis type) at the age of 15. She received a restorative proctocolectomy with the stapled ileo-anal canal J pouch anastomosis at the age of 22, but developed a rectovaginal fistula originating from the residual rectum at the eighth postoperative day. The surgical treatment of the fistula was repeated four times in our service (first was simple sutures and temporally ileostomy, second was transanal repair using mucosal flap, third was transanal repair using mucosal flap and temporally ileostomy, and fourth was transanal repair using mucosal flap) during the 10-year period, but it recurred in intervals ranging between 2 months and 5 years after the operation. The last recurrence occurred at the age of 32, but the surgical repair was considered to be difficult and a conservative treatment was indicated. At the age of 40, she developed frequent diarrhea (30 times/day), including bloody excrement, with consequent increasing of drainage from the rectovaginal fistula. Due to body weight loss associated with difficulty of dietary ingestion, she was admitted for a treatment.
After the hospital admission, intravenous hyperalimentation with restriction of oral administration has been continued for 1 week. Though the dehydration and denutrition were significantly improved as well as the stool frequency, the symptoms from the rectovaginal fistula persisted. Figure 1 shows the abdominal magnetic resonance imaging (MRI) and barium-enema study of the rectovaginal fistula before starting treatment. Surgical treatment was considered unfeasible, therefore the conservative management with infusions of infliximab was advocated. After confirmed to be negative for tuberculosis and the informed consent was obtained, the infliximab-based treatment, consisting of intravenous infusions of infliximab at a dose of 5 mg/kg, at day 0 and weeks 2, 6, 10 and then every 8 weeks, was started. Figure 2 shows the time course of the symptomatic changes after the admission. Four weeks after the first infusion, drainage from the fistula was evidently reduced, and 2 weeks later, the fistula was completely closed. Thereafter, no recurrence of the fistula is observed for at least 26 months. We continue the administration of infliximab at the outpatient. Figure 3 shows the results of the imaging study 1 year after the start of infliximab therapy. The closure of the fistula was confirmed by the abdominal MRI and the barium-enema study.