Intest Res.  2017 Oct;15(4):535-539. 10.5217/ir.2017.15.4.535.

Steroid-refractory extensive enteritis complicated by ulcerative colitis successfully treated with adalimumab

• Okabayashi S
• Kobayashi
• Sujino T
• Ozaki R
• Umeda S
• Toyonaga T
• Saito E
• Nakano M
• Tablante M
• Morinaga S
• Hibi T

• KMID: 2396405
• DOI: http://doi.org/10.5217/ir.2017.15.4.535

Abstract

Extracolonic involvement of the gastrointestinal tract is extremely uncommon in ulcerative colitis (UC) and rarely found in the upper gastrointestinal tract or in postoperative cases since it typically responds to steroids. Here we report a case of UC complicated by extensive ileal inflammation that was refractory to steroids. A 20-year-old man was diagnosed with UC of typical pancolitis without ileal involvement and started treatment with pH-dependent mesalazine and oral prednisolone. Although his symptoms transiently resolved, the condition flared when the steroid dose was tapered down. Computed tomography revealed marked thickening of the ileal wall, and capsule endoscopy and balloon-assisted enteroscopy found diffuse mucosal inflammation with ulcers in the ileum. On the contrary, the inflammation in the colon and rectum was improving. Since the response to the second steroid course was inadequate, treatment with adalimumab and 6-mercaptopurine was initiated and finally achieved clinical and endoscopic remission. The investigation of small intestinal lesions is necessary in patients with UC whose clinical deterioration cannot be explained by colonic lesions.

Keyword

Ulcerative colitis; Enteritis; Inflammatory bowel disease; Capsule endoscopy; Balloon-assisted enteroscopy

MeSH Terms

6-Mercaptopurine
Adalimumab*
Capsule Endoscopy
Colitis, Ulcerative*
Colon
Enteritis*
Gastrointestinal Tract
Humans
Ileum
Inflammation
Inflammatory Bowel Diseases
Mesalamine
Prednisolone
Rectum
Steroids
Ulcer*
Upper Gastrointestinal Tract
Young Adult
6-Mercaptopurine
Adalimumab
Mesalamine
Prednisolone
Steroids

Figure

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  Fig. 1 Clinical course of a patient who achieved clinical remission. ADA, adalimumab; ED, elemental diet; PSL, prednisolone; GMA, granulocyte monocyte apheresis; 6MP, 6-mercatopurine.

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  Fig. 2 Endoscopic findings prior to diagnosis and treatments of UC. Colonoscopy revealed no inflammation within the terminal ileum (A), and inflammation with diffused friable mucosa throughout the entire colon and rectum with erosions in A B the sigmoid colon and rectum (B).

• 

  Fig. 3 CT and endoscopic findings of UC after tapering of the steroid treatment. Widespread inflammation in the small intestine was observed via CT (A, arrows). Balloon-assisted enteroscopy revealed severe extensive inflammation with multiple ulcers spreading in the ileum and mild inflammation in the terminal ileum, colon, and rectum (B). Capsule endoscopy discovered diffuse mucosal inflammation with erosions and ulcers in the middle to distal ileum (C).

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  Fig. 4 Biopsy specimen taken from the ileum revealing moderate chronic inflammation with neutrophilic and lymphoplasmacytic inflammation with erosion (H&E, ×40).

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  Fig. 5 Endoscopic findings after treatment for extensive involvement in the small intestine. Balloon-assisted enteroscopy revealed remission in the small intestine.

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