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

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.

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

“…We searched the PubMed and Embase databases using the terms "ulcerative colitis" and "post-colectomy enteritis" or "pan-enteritis" or "diffuse enteritis" or "pre-stomal enteritis" or "small bowel lesion" in English before June 1, 2020. Thirty-seven cases were previously reported [10][11][12][13][14][26][27][28][29][30][31][32]. This rare disease with distinct endoscopic inflammation of the stomach and small bowel resembles inflammation in the colon with UC.…”

“…Intravenous corticosteroids and azathioprine were the most frequently reported treatments that were immediately administered [10,11]. TAC, IFX, and ADA were reported in only case reports [13,29,30]. A chimeric monoclonal antibody directed against TNFα is commonly effective for patients with UC [34,35].…”