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© EFIM 2026 - European Journal of Case Reports in Internal Medicine - Doi: 10.12890/2026_007112 1
OCTREOTIDE AS A BRIDGE TO ANTI-TNF THERAPY IN
SEVERE FISTULIZING CROHN’S DISEASE COMPLICATED
BY A CLINICALL Y HIGH-OUTPUT ENTEROCUTANEOUS
FISTULA: A CASE REPORT AND LITERATURE REVIEW
Essadi Btissam , Benderrou Mouhssine, Ouiam Elmqaddem, Hajar Koulali, Abdelkrim Zazour, Zahi Ismaili,
Ghizlane Kharrasse
(LAPOD) Research Laboratory of Pathology and Digestive Oncology, Faculty of Medicine and Pharmacy, Mohammed First University,
Oujda, Morocco
Department of Hepato-Gastroenterology, Mohammed VI University Hospital Center, Oujda, Morocco
Corresponding author’s e-mail: btissamfg.1995@gmail.com
Received: 30/05/2026
Accepted: 22/06/2026
Published: 15/07/2026
Conflicts of Interests: The Authors declare that there are no competing interests.
Patient Consent: Written informed consent was obtained from the patient for publication of this case report and the accompanying images.
This article is licensed under a CC Attribution-NonCommercial-NoDerivatives 4.0 License
How to cite this article: Btissam E, Mouhssine B, Elmqaddem O, Koulali H, Zazour A, Ismaili Z, Kharrasse G. Octreotide as a bridge to Anti- TNF therapy in
severe fistulizing Crohn’s disease complicated by a clinically high-output enterocutaneous fistula: A case report and literature review. EJCRIM 2026;13:doi:10
.12890/2026_007112
ABSTRACT
Introduction: Fistulizing Crohn’s disease is a severe phenotype of inflammatory bowel disease and may be complicated
by enterocutaneous fistulas, which are associated with substantial morbidity due to sepsis, fluid and electrolyte
disturbances, skin damage, and severe malnutrition. Anti-tumour necrosis factor agents, particularly infliximab, represent
a cornerstone of medical therapy for fistulizing Crohn’s disease. However, their initiation may need to be temporarily
deferred in patients with septic risk, uncontrolled fistula output, or profound nutritional impairment.
Case report: We report the case of a 54-year-old man with severe stenosing and fistulizing ileocolonic Crohn’s
disease, classified as A3L3B3P0 according to the Montreal classification, complicated by a long-standing -clinically
high-output- enterocutaneous fistula. On admission, he had severe malnutrition, with a body mass index of 13.8 kg/
m², hypoalbuminemia at 24 g/L, hyponatremia, elevated C-reactive protein, and multiple complex fistulous tracts on
abdominopelvic computed tomography, without a drainable deep collection.
Because immediate infliximab therapy was considered unsafe, a multidisciplinary -bridging strategy- was initiated,
combining nutritional optimization, local wound care, correction of deficiencies, and subcutaneous octreotide at a dose
of 100 µg every 8 hours for one month. This approach was associated with a marked reduction in fistula output, from
six to seven pouch changes per day to one daily change, progressive improvement of skin lesions, weight gain without
edema, increased serum albumin, and decreased systemic inflammation. These improvements allowed subsequent
initiation of infliximab therapy.
Conclusion: This case suggests that octreotide may be useful as -adjunctive antisecretory bridge therapy- in selected
patients with Crohn’s disease-associated clinically high-output enterocutaneous fistulas when biologic therapy must be
delayed. Its role should not be interpreted as definitive fistula therapy, but rather as part of a broader strategy aimed
at reducing fistula output, improving nutritional and inflammatory status, and creating safer conditions for disease-
modifying treatment.
© EFIM 2026 - European Journal of Case Reports in Internal Medicine - Doi: 10.12890/2026_007112 2
KEYWORDS
Crohn’s disease, enterocutaneous fistula, octreotide, somatostatin analogues, bridging therapy
LEARNING POINTS
• This case highlights the potential role of octreotide as adjunctive antisecretory bridge therapy in Crohn’s disease-
associated clinically high-output enterocutaneous fistulas when immediate biologic therapy is considered unsafe
because of severe malnutrition, major inflammatory burden, or septic risk.
• This observation emphasizes the importance of multidisciplinary stabilization before biologic therapy, including
nutritional optimization, correction of metabolic and electrolyte abnormalities, local wound care, and inflammatory control
in fragile patients with complicated fistulizing Crohn’s disease.
• This case demonstrates that a conservative strategy integrating octreotide may achieve substantial reduction in fistula
output, improvement of nutritional and biological status, and creation of safer conditions for subsequent disease-
modifying therapy initiation.
INTRODUCTION
Crohn’s disease is a chronic inflammatory bowel disease
characterized by segmental transmural inflammation, which
may lead to stricturing and penetrating complications [1,2].
During the disease course, approximately 20–40% of
patients develop a penetrating phenotype, including
internal or external fistulas [1,2]. Enterocutaneous fistulas are
abnormal communications between the gastrointestinal
tract and the skin. In Crohn’s disease, they may occur
spontaneously as a consequence of penetrating disease or
develop after abdominal surgery. Although uncommon, they
are associated with substantial morbidity, mainly related
to chronic external drainage, sepsis, fluid and electrolyte
disturbances, skin injury, and severe malnutrition[1,2].
Management requires a multidisciplinary strategy
focused on sepsis control, drainage of collections when
present, correction of fluid and electrolyte abnormalities,
skin protection, reduction of fistula output, anatomical
assessment, and nutritional optimization [2,3]. Anti-tumour
necrosis factor (TNF) therapy, particularly infliximab,
remains a key treatment for fistulizing Crohn’s disease, but
its initiation may need to be temporarily deferred in patients
with septic risk or profound nutritional impairment[3].
Somatostatin analogues, especially octreotide, reduce
gastrointestinal secretions and may rapidly decrease fistula
output. Most available evidence concerns postoperative
or mixed enterocutaneous fistulas, while data in Crohn’s
disease remain limited to small series and case reports [4,5].
Therefore, octreotide should be considered -adjunctive
bridging therapy- rather than definitive fistula treatment.
We report a case of severe stenosing and fistulizing
ileocolonic Crohn’s disease complicated by a -clinically
high-output- enterocutaneous fistula, in which octreotide
was used to reduce fistula output, improve nutritional
status, and allow subsequent initiation of infliximab.
CASE DESCRIPTION
A 54-year-old Moroccan man with a history of pulmonary
tuberculosis successfully treated in 2014, right femoral
fracture managed by osteosynthesis, and cholecystectomy
for acute cholecystitis in 2021 was followed for Crohn’s
disease diagnosed in 2006.
At diagnosis, he underwent surgery for intestinal
obstruction, consisting of a right hemicolectomy with
terminal ileal resection and ileotransverse anastomosis.
The postoperative course was complicated by an
anastomotic leak on postoperative day 8, requiring
reoperation with repair of a transverse colonic leak and
creation of a terminal ileostomy. In 2025, he developed
peritonitis secondary to an iatrogenic post-colonoscopy
small-bowel perforation, requiring peritoneal lavage and
drainage, with closure of a small-bowel-to-abdominal-wall
fistula.
Regarding medical therapy, he had received oral
5-aminosalicylates for four years, with poor adherence,
before discontinuing both follow-up and maintenance
treatment in 2010. A previous colonoscopy showed
macroscopically normal small-bowel mucosa and
erythematous congestive rectosigmoiditis with areas of
mucosal sparing.
The current episode began two years before admission,
with progressive development of an enterocutaneous fistula
in the right iliac fossa, draining purulent and enteric fluid,
associated with a second fistulous opening on the midline
laparotomy scar. The fistula was clinically high-output,
requiring six to seven pouch changes per day. The patient
also reported diffuse abdominal pain and intermittent
obstructive symptoms.
On admission, he was severely malnourished, with a World
Health Organization performance status of 1, a weight of
45 kg, a body mass index of 13.8 kg/m 2, and a Nutritional
Risk Index of 62. Abdominal examination revealed four
fistulous openings in the right iliac fossa with purulent
discharge (Fig. 1) , as well as a fistulous opening on the
midline laparotomy scar with surrounding inflammatory skin
changes (Fig. 2). An ostomy pouch was present in the left
iliac fossa.
Laboratory investigations showed elevated inflammatory
© EFIM 2026 - European Journal of Case Reports in Internal Medicine - Doi: 10.12890/2026_007112 3
markers, with C-reactive protein at 110 mg/l, platelet
count at 467 ×10 9/l, and white blood cell count at 8.5
×109/l. Procalcitonin was 0.11 ng/ml. The patient also had
normocytic normochromic anaemia, with haemoglobin at
11.4 g/dl, severe hypoalbuminemia at 24 g/l, hyponatremia
at 126 mmol/l, and preserved renal function. Nutritional
assessment showed vitamin D deficiency at 9.6 ng/ml and
low ferritin at 19.31 ng/ml. Microbiological cultures were
negative.
Contrast-enhanced abdominopelvic computed tomography
scan showed inflammatory ileal wall thickening with
stenotic segments and upstream bowel dilatation,
associated with multiple entero-enteric and ileosigmoid
fistulous tracts. It also confirmed an enterocutaneous fistula
(Fig. 3) in the right iliac fossa, with marked perilesional fat
stranding but no drainable deep collection.
Because of severe malnutrition, clinically high-output fistula
drainage, elevated inflammatory markers, and septic risk,
immediate initiation of infliximab was temporarily deferred.
A multidisciplinary conservative strategy was initiated,
combining local wound care with a zinc-based barrier
ointment, thromboprophylaxis, correction of vitamin and
trace element deficiencies, and subcutaneous octreotide at
a dose of 100 µg every 8 hours for one month. Nutritional
support included Modulen ® IBD, enteral nutrition, a
high-calorie, high-protein, low-fat, low-residue diet, and
supplemental parenteral nutrition with Oliclinomel®.
After one month, the patient’s condition improved markedly.
He gained 14 kg, increasing from 45 kg to 59 kg, without
oedema or clinical signs of fluid overload. Fistula output
decreased from six to seven pouch changes per day
to one daily pouch change, and the surrounding skin
lesions progressively healed (Fig. 4). Laboratory tests also
improved, with C-reactive protein decreasing to 12 mg/l,
platelet count to 412 ×10 9/l, and serum albumin increasing
to 32 g/l. Renal function and serum electrolytes normalized.
After clinical, nutritional, and inflammatory stabilization, the
patient received the first induction dose of infliximab at 5
mg/kg as disease-modifying therapy for Crohn’s disease.
DISCUSSION
Crohn’s disease is characterized by chronic transmural
inflammation, which may lead to stricturing and penetrating
complications. The penetrating phenotype is observed
in approximately 20–40% of patients during the disease
course and is one of the most severe patterns of Crohn’s
disease[1,2]. Fistulas may be perianal, entero-enteric,
enterovesical, rectovaginal, or enterocutaneous. Among
these, enterocutaneous fistulas are relatively uncommon
but remain particularly challenging because they combine
ongoing intestinal inflammation, external enteric losses,
septic risk, skin injury, and nutritional depletion[1,2].
An enterocutaneous fistula is defined as an abnormal
communication between the gastrointestinal tract and
the skin, resulting in external drainage of enteric contents.
In Crohn’s disease, it may occur spontaneously as a
consequence of transmural inflammation and penetrating
disease, or develop after abdominal surgery [1,2]. Its
prognosis depends on fistula anatomy, output, distal
obstruction, active sepsis, nutritional status, and underlying
inflammatory activity. High-output fistulas expose patients
to fluid and electrolyte depletion, dehydration, renal
dysfunction, severe malnutrition, skin injury, prolonged
hospitalization, and impaired quality of life[1,2].
Management requires a multidisciplinary approach
involving gastroenterologists, colorectal surgeons,
radiologists, nutrition specialists, wound-care nurses,
and, when necessary, infectious disease specialists. Initial
management should focus on sepsis control, drainage of
collections when present, correction of fluid and electrolyte
disorders, skin protection, anatomical assessment,
reduction of fistula output, and nutritional rehabilitation[2,3].
Nutritional optimization is a cornerstone of management.
Patients with high-output enterocutaneous fistulas are at
high risk of protein-energy malnutrition because of enteric
Figure 1. Baseline multiple fistulous openings in the right iliac
fossa.
Figure 2. Midline laparotomy-scar fistula after local cleansing,
before initiation of octreotide therapy.
© EFIM 2026 - European Journal of Case Reports in Internal Medicine - Doi: 10.12890/2026_007112 4
losses, reduced oral intake, systemic inflammation, and
hypercatabolism. Enteral nutrition should be preferred
whenever feasible because of its trophic effect on the
intestinal mucosa, while supplemental or total parenteral
nutrition may be required when enteral intake is insufficient
or fistula output remains excessive. Correction of
micronutrient deficiencies, trace element depletion, and
hypoalbuminemia is essential before definitive medical or
surgical treatment can be safely considered[2].
Somatostatin is an endogenous peptide hormone with
broad inhibitory effects on the gastrointestinal tract.
It reduces gastric, pancreatic, biliary, and intestinal
secretions, decreases intestinal motility, and may
reduce splanchnic blood flow. Octreotide, marketed as
Sandostatin®, is a synthetic somatostatin analogue with a
longer half-life and more convenient administration. These
pharmacological properties provide the rationale for its
use in enterocutaneous fistulas, mainly as an antisecretory
agent aimed at reducing fistula output and facilitating fluid,
electrolyte, and nutritional stabilization[4].
Most available evidence for somatostatin and its analogues
comes from postoperative or mixed gastrointestinal
fistula populations rather than Crohn’s disease-specific
enterocutaneous fistulas. In these settings, somatostatin-
based therapies have been associated with reduction of
fistula output and, in some studies, shorter time to closure
and shorter hospital stay. However, their effect on definitive
spontaneous closure remains inconsistent, and no clear
mortality benefit has been demonstrated [5–7]. Therefore,
these agents should be considered as adjunctive output-
reducing therapy, not definitive fistula-closing treatment.
A major unresolved issue concerns the optimal dosing
regimen of somatostatin analogues in Crohn’s disease-
associated enterocutaneous fistulas. In postoperative or
mixed gastrointestinal fistula populations, octreotide is
commonly administered subcutaneously, often at doses
ranging from 100 µg three times daily to higher regimens,
or by continuous intravenous infusion depending on fistula
output and clinical severity. However, no validated dose,
duration, or response-based adjustment strategy has been
established specifically for Crohn’s disease-associated
enterocutaneous fistulas. The few available reports used
heterogeneous regimens, including the early clinical
experience reported by Al-Karawi et al. [8] and the higher-
dose regimen described in Lavy’s pilot study[9].
The report by Lavy and Y asin is particularly relevant to
the present case, as it remains one of the few Crohn’s
disease-specific publications describing octreotide use for
enterocutaneous fistulas [9]. In this pilot study, five patients
with Crohn’s disease-associated enterocutaneous fistulas
were treated with octreotide 300 µg subcutaneously four
times daily for eight weeks. Fistula closure was achieved
in four of the five patients; however, recurrence with
subsequent surgery occurred in some cases, highlighting
both the potential benefit and the limitations of this
approach[9]. These findings support the use of octreotide
as an adjunctive output-reducing therapy in selected
patients. In this context, our observation adds to this limited
literature by illustrating the use of octreotide as a short-term
antisecretory bridge before anti- TNF therapy, integrated
into a broader multidisciplinary strategy aimed at improving
nutritional, inflammatory, and clinical stability before
infliximab initiation.
The available Crohn-specific cases, together with
the present observation, are summarized in T able 1.
However, this table should be interpreted as a descriptive
summary of limited published experience rather than as
evidence supporting a standardized octreotide regimen
in Crohn’s disease-associated enterocutaneous fistulas.
In the present case, octreotide 100 µg every 8 hours was
selected by extrapolation from general enterocutaneous
fistula management rather than from disease-specific
dosing evidence. Therefore, octreotide dosing in this setting
should be individualized, short-term, clinically monitored,
and reassessed according to fistula output, nutritional
response, tolerance, and the possibility of initiating
definitive Crohn’s disease therapy.
Current guidelines and expert reviews emphasize
that surgery has a central role in complicated Crohn’s
Figure 3. Contrast-enhanced abdominopelvic CT scan showing
an enterocutaneous fistulous tract in the right iliac fossa.
Figure 4. Improved midline laparotomy-scar fistula after one
month of octreotide-based conservative management.
© EFIM 2026 - European Journal of Case Reports in Internal Medicine - Doi: 10.12890/2026_007112 5
disease-associated fistulas, particularly in the presence
of peritonitis, perforation, haemorrhage, uncontrolled
abdominal sepsis, undrained abscess, or failure of
conservative management[2]. However, outside emergency
settings, surgery should preferably be delayed until
sepsis is controlled, nutritional status is improved,
electrolyte disturbances are corrected, and inflammatory
activity is better controlled. In severely malnourished or
clinically fragile patients, premature surgery may carry
substantial morbidity; therefore, a bridging strategy aimed
at stabilization is clinically relevant when no immediate
surgical indication exists[2,3].
Anti- TNF agents, particularly infliximab, remain the best-
established biologic therapy for fistulizing Crohn’s disease.
In the GETAID cohort, Amiot et al. reported complete
closure of enterocutaneous fistulas in approximately one-
third of patients treated with anti- TNF therapy 10]. In clinical
practice, the role of anti- TNF therapy in this setting is not
to replace urgent surgery when surgery is mandatory, but
to control active Crohn’s disease, promote fistula healing
when anatomically feasible, and potentially avoid or
delay surgery in selected fragile patients after adequate
stabilization[10].
In the present case, octreotide was used as part of a
broader multidisciplinary conservative strategy, not as
definitive fistula therapy but as bridge therapy before
disease-modifying treatment. The patient had multiple
adverse prognostic factors, including multiple fistulous
tracts, clinically high-output drainage requiring six to seven
pouch changes per day, severe malnutrition with a body
mass index of 13.8 kg/m 2, marked hypoalbuminemia,
hyponatremia, elevated inflammatory markers, complex
ileal and ileosigmoid fistulas on computed tomography,
and septic risk. Hypoalbuminemia and poor nutritional
status are well-recognized adverse prognostic factors in
enterocutaneous fistulas [2]. Immediate infliximab therapy
was therefore temporarily deferred.
After one month of combined management, including
wound care, thromboprophylaxis, correction of vitamin and
trace element deficiencies, enteral nutrition, supplemental
parenteral nutrition, and octreotide, the patient showed
marked clinical and biological improvement. Fistula output
decreased substantially, skin lesions improved, body
weight increased without oedema, serum albumin rose,
serum electrolytes normalized, and C-reactive protein
decreased. This stabilization created safer conditions for
the initiation of infliximab as disease-modifying therapy,
with the aim of controlling the underlying Crohn’s disease
and avoiding immediate surgery in a severely fragile
patient.
The main value of this observation is therefore not to
suggest that octreotide can replace anti- TNF therapy or
surgery, but to support its potential role as adjunctive
antisecretory bridging therapy in carefully selected patients
Table 1. Published Crohn’s disease-associated enterocutaneous fistulas treated with somatostatin analogues.
Source Patient/disease phenotype Initial fistula
output Drug and dose Duration Response after
treatment Final outcome
Al-Karawi and
Ahmed[8]
24-year-old female with
Crohn’s disease and
recurrent enterocutaneous
fistulas
High-volume
fistula discharge
Octreotide 50
µg SC once
daily, gradually
increased to 50
µg SC three times
daily
Not clearly
specified
Gradual reduction
in fistula discharge;
fistulas began to close
after the first week
Clinical improvement,
with no further
recurrence reported
during follow-up
Lavy and Y asin[9]
17-year-old female with
terminal ileal Crohn’s
disease; enterocutaneous
fistula after abscess
drainage
Not reported
Octreotide 300
µg SC four times
daily
8 weeks Fistula closure after 4
weeks
Secondary
reopening after upper
gastrointestinal series;
surgery required
Lavy and Y asin[9]
50-year-old male with
long-standing Crohn’s
disease; postoperative
enterocutaneous fistula
Not reported
Octreotide 300
µg SC four times
daily
8 weeks Fistula closure after 5
weeks
Sustained closure at
24 months
Lavy and Y asin[9]
40-year-old male
with diffuse Crohn’s
disease; spontaneous
enterocutaneous fistula
Not reported
Octreotide 300
µg SC four times
daily
8 weeks Fistula closure after 3
weeks
Sustained closure at
19 months
Lavy and Y asin[9]
37-year-old male with
ileal Crohn’s disease;
ileocutaneous fistula after
abscess drainage
Not reported
Octreotide 300
µg SC four times
daily
8 weeks Fistula closure within
2 weeks
Fistula recurrence
after 1 year; surgery
subsequently
performed
Lavy and Y asin[9]
45-year-old male with
Crohn’s disease involving
the terminal ileum and
rectum; cologluteal fistula
Not reported
Octreotide 300
µg SC four times
daily
8 weeks Fistula closure after 6
weeks
Sustained closure at
12 months
Present case
54-year-old male with severe
stenosing and fistulizing
ileocolonic Crohn’s disease
complicated by a clinically
high-output enterocutaneous
fistula
Clinically high-
output fistula
requiring six to
seven pouch
changes per day
Octreotide 100 µg
SC every 8 hours 1 month
Marked reduction in
fistula output to one
pouch change per day,
with improvement of
skin lesions
Nutritional and
inflammatory
improvement, allowing
subsequent initiation
of infliximab
© EFIM 2026 - European Journal of Case Reports in Internal Medicine - Doi: 10.12890/2026_007112 6
with Crohn’s disease-associated clinically high-output
enterocutaneous fistulas. By reducing enteric losses and
improving the nutritional and inflammatory environment,
octreotide may help create more favourable conditions
for subsequent biologic therapy or delayed surgery when
indicated.
This case has several limitations. As a single observation,
it cannot establish causality. The favourable outcome likely
resulted from the combined effect of multidisciplinary care,
nutritional support, local wound management, correction
of deficiencies, and octreotide. In addition, fistula output
was assessed clinically by pouch-change frequency rather
than quantified in ml/day. The dose of octreotide used in
this case was also selected by extrapolation from general
enterocutaneous fistula practice, because no Crohn’s-
specific dosing recommendations are available. Further
studies are required to define the optimal indications,
dose, duration, and true clinical impact of somatostatin
analogues in Crohn’s disease-associated enterocutaneous
fistulas.
CONCLUSION
Octreotide may represent a useful adjunctive antisecretory
bridge therapy in selected patients with Crohn’s disease-
associated clinically high-output enterocutaneous fistulas
when immediate biologic therapy is unsafe because of
septic risk, severe malnutrition, or major clinical instability.
In the present case, octreotide was associated with marked
reduction in fistula output, improvement of skin lesions,
nutritional recovery, and biological stabilization, allowing
subsequent initiation of infliximab. However, octreotide
should not be considered a substitute for definitive Crohn’s
disease therapy or surgery when surgery is mandatory.
Its role is best understood as part of a multidisciplinary
stabilization strategy aimed at creating safer conditions for
anti- TNF therapy or delayed surgical management.
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