Clinical Features and Therapeutic Outcomes of Post-colectomy Enteritis with Ulcerative Colitis

Abstract

Objectives: Few reports are available on post-colectomy enteritis (PCE) with ulcerative colitis (UC), which can be severe and sometimes fatal. The clinical characteristics are unclear, and treatment and diagnosis protocols have not been established. We aimed to investigate the incidence, clinical characteristics, diagnostic criteria, and therapeutic outcomes of PCE in this study. Methods: Patients with UC who underwent colectomy between April 2010 and December 2019 were included in this study. We retrospectively analyzed patients who developed PCE and excluded patients with other forms of enteritis. Results: We performed 829 colectomies because of a preoperative diagnosis of UC. Eleven and four patients were diagnosed with Crohn's disease and indeterminate colitis after surgery, respectively; 22 patients developed enteritis in the perioperative period. We excluded six patients with backwash ileitis, five with prepouch ileitis, three with infectious enteritis, and one with ischemic enteritis. In total, 7/814 (0.8%) patients developed PCE. All patients with PCE had pancolitis. PCE was observed a median of 33 (12-248) days after surgery. Endoscopy showed friable and granular mucosa. The extent of disease included various types such as pan-enteritis with diffuse type, pan-enteritis and mild inflammation in the middle ileum, and only ileitis. Gastroduodenitis-associated UC developed in 6/7 cases. All patients improved with tumor necrosis factor alpha (TNFα) antagonists even if TNFα antagonists had not been effective for colitis. Conclusions: PCE was rare. The mucosal endoscopic findings were similar to those of UC, and the extent of disease varied. TNFα antagonist administration for PCE was effective.

Postcolectomy Enteritis in a Pediatric Patient With Ulcerative Colitis

“…This is the first published case of a pediatric patient with PCE, an entity previously only described in adults. PCE may be difficult to diagnose; in patients initially diagnosed with UC who develop small bowel inflammation following colectomy, the concern is often misdiagnosed Crohn’s disease ( 6 , 7 ). In the immediate postoperative period, one must also consider surgical complications such as wound infection, anastomotic leak, or ischemia, functional and mechanical stoma complications including stricture and prolapse, and bacterial, viral, and fungal infectious complications including Clostridium difficile infection (Table 1 ) ( 3 , 7 ).…”

“…Our patient did not require further immunosuppressive therapy and ultimately had improvement in symptoms with corticosteroid taper and supportive care. In a study of over 800 adult patients with UC status postcolectomy, 7 developed PCE, 3 of whom did not respond to corticosteroids ( 6 ). There is no consensus on optimal treatment for PCE, and further studies are needed to understand the natural history and optimal management of pediatric postcolectomy enteritis.…”

“…The pathogenesis of PCE is unknown, though it is thought to be due to immune dysregulation with increased cytokine and inflammatory cell response. Prior cases have been managed with systemic corticosteroids and antitumor necrosis factor alpha (anti-TNFa) medications (3)(4)(5)(6)(7). In the adult literature, Horio et al (6) found the incidence of PCE to be around 0.8%.…”

“…Prior cases have been managed with systemic corticosteroids and antitumor necrosis factor alpha (anti-TNFa) medications (3)(4)(5)(6)(7). In the adult literature, Horio et al (6) found the incidence of PCE to be around 0.8%. No cases of PCE are reported in pediatric patients, so little is known about presentation, natural history and outcomes.…”

Endoscopic Evaluation of the Ileal Pouch

“…The presence of small-bowel CD diagnosed on the basis of ileoscopy via stoma may preclude the subsequent IPAA. Patients with EI or LI and persistent high ileostomy output should also be evaluated for infectious enteritis (particularly Clostridium difficile enteropathy 21 ) and postcolectomy enteritis syndrome, 6,22 in which ileoscopy plays a key role.…”