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Li M, Xu T, Ruan G, Ou C, Tan B, Zhang S, Li X, You Y, Zhou W, Li J, Li J. Comprehensive insights into pathogenesis, diagnosis, treatment, and prognosis in adult autoimmune enteropathy. Orphanet J Rare Dis 2025; 20:208. [PMID: 40317016 PMCID: PMC12046689 DOI: 10.1186/s13023-025-03731-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 04/11/2025] [Indexed: 05/04/2025] Open
Abstract
Autoimmune enteropathy (AIE) constitutes a diverse array of disorders characterized by immune dysregulation and gastrointestinal manifestations, chiefly chronic diarrhea. Due to the small number of reported cohorts, the current knowledge and understanding of adult-onset AIE is rare compared with pediatric or syndromic AIE. Pathogenesis might involve genetic predisposition, aberrant immune homeostasis, comorbidities of autoimmune diseases and environmental trigger. Diagnosis relies on a comprehensive assessment encompassing clinical evaluation, laboratory tests, endoscopic findings and histopathological features, yet distinguishing AIE from other disorders with similar presentations poses diagnostic challenges. Treatment strategies predominantly center on immunosuppressive therapies, exhibiting varied efficacy among individuals. Supportive treatment and prevention and management of complications are also important for prognosis. The prospectives of future researches need to explore the genetic and immunological mechanism, the diagnostic modalities and the treatment strategies to improve patient outcomes.
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Affiliation(s)
- Muhan Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tianming Xu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gechong Ruan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chengzhu Ou
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bei Tan
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengyu Zhang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoqing Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan You
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Weixun Zhou
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Ji Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jingnan Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Toritani K, Kimura H, Maebashi M, Kurimura K, Haruyama S, Nakamori Y, Matsubayashi M, Kunisaki R, Tanaka R, Fujii S, Endo I. Massive bleeding and perforation due to post-colectomy pan-enteritis with a significant response to biologic in a patient with ulcerative colitis: a case report. Surg Case Rep 2024; 10:201. [PMID: 39196494 PMCID: PMC11358364 DOI: 10.1186/s40792-024-02003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Accepted: 08/19/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Post-colectomy pan-enteritis in ulcerative colitis (UC) is very rare, but it is often severe and fatal. We present a case of massive bleeding and perforation due to post-colectomy pan-enteritis, which showed a significant response to biologics in a UC patient. CASE PRESENTATION A 30-year-old woman with a 5-month history of pancolitis UC underwent subtotal colectomy with ileostomy and mucosal fistula for refractory UC. She was diagnosed with small bowel obstruction on postoperative day (POD) 8 and bowel bleeding was observed on POD18. Reoperation was performed for bowel obstruction and bleeding on POD20. Intraoperatively, adhesive small bowel obstruction in the ileum and multiple erosions and ulcers with perforation were observed throughout the small bowel. We diagnosed post-colectomy pan-enteritis, and jejunostomy, lavage, adhesiolysis, and a simple closure of the perforated ileum were performed. High-dose steroid therapy for pan-enteritis was administered immediately after reoperation, and infliximab was administered because of worsening bleeding on day 3 after reoperation. Bleeding decreased one day after biologic administration and bleeding completely disappeared on day 10 after biologic administration. Specimens obtained from the terminal ileum at colectomy showed a normal ileum without inflammation and villus atrophy, while specimens from the perforated ileum showed congestion, villous atrophy, epithelial erosion, and mononuclear cell infiltration. No cryptitis, crypt distortion, or basal plasmacytosis (common characteristics in UC) were observed in either specimen. CONCLUSION An early diagnosis and intervention are important for post-colectomy pan-enteritis, and infliximab may be effective. Post-colectomy pan-enteritis with a multiple ulcer phenotype has different histological characteristics from UC and may have a different pathogenesis.
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Affiliation(s)
- Kenichiro Toritani
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan.
| | - Manabu Maebashi
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Kazuki Kurimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Serina Haruyama
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Yoshinori Nakamori
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Mao Matsubayashi
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Reiko Tanaka
- Department of Pathology, Yokohama City University Medical Center, Yokohama, Japan
| | - Satoshi Fujii
- Department of Pathology, Yokohama City University Medical Center, Yokohama, Japan
- Department of Molecular Pathology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Pathology, Yokohama City University Hospital, Yokohama, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Guo C, He S, Wang H. Case report: Successful treatment of ulcerative colitis-related post-colectomy enteritis refractory to multiple therapies with ustekinumab. Front Immunol 2024; 15:1297508. [PMID: 38433841 PMCID: PMC10904456 DOI: 10.3389/fimmu.2024.1297508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Ulcerative colitis-related severe post-colectomy enteritis is a rare condition. A few cases have undergone successful treatment with corticosteroids, Cyclosporine, Azathioprine, and Infliximab. We aim to evaluate the treatment outcome of ustekinumab in this rare case. Here we describe a 56-year-old woman with post-colectomy enteritis refractory to multiple therapies. Finally, the patient was administered with ustekinumab treatment. Under monitoring, the feces volume of the patient decreased from 5000-7000 mL per day to 1700-2000 mL. Over a one-year follow-up period, the patient gradually gained body weight, with the stoma drainage of formed brown stool. And the villi of the small intestinal mucosa restore growth. To our knowledge, this is the first report that indicates ustekinumab could be a treatment selection for ulcerative colitis-related severe post-colectomy enteritis.
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Affiliation(s)
| | | | - Huahong Wang
- Department of Gastroenterology, Peking University First Hospital, Beijing, China
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Horio Y, Uchino M, Hori K, Kusunoki K, Minagawa T, Kuwahara R, Kataoka K, Beppu N, Ikeda M, Ikeuchi H. Clinical Features and Therapeutic Outcomes of Post-colectomy Enteritis with Ulcerative Colitis. JOURNAL OF THE ANUS RECTUM AND COLON 2021; 5:405-413. [PMID: 34746505 PMCID: PMC8553349 DOI: 10.23922/jarc.2021-031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/06/2021] [Indexed: 12/23/2022]
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.
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Affiliation(s)
- Yuki Horio
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Motoi Uchino
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Kazutoshi Hori
- Department of Intestinal Inflammation Research, Hyogo College of Medicine, Hyogo, Japan
| | - Kurando Kusunoki
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Tomohiro Minagawa
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Ryuichi Kuwahara
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Kozo Kataoka
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Naohito Beppu
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Masataka Ikeda
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroki Ikeuchi
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
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Zhou QY, Zhou WX, Sun XY, Wu B, Zheng WY, Li Y, Qian JM. Autoimmune enteropathy and primary biliary cholangitis after proctocolectomy for ulcerative colitis: A case report and review of the literature. World J Gastroenterol 2021; 27:4929-4938. [PMID: 34447236 PMCID: PMC8371508 DOI: 10.3748/wjg.v27.i29.4929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/29/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Autoimmune enteropathy (AIE) and primary biliary cholangitis (PBC) are both immune-mediated diseases. AIE or PBC complicated with ulcerative colitis (UC) are rare. There are no cases of AIE and PBC diagnosed after proctocolectomy for UC reported before, and the pathogenesis of these comorbidities has not been revealed.
CASE SUMMARY A middle-aged woman diagnosed with UC underwent subtotal colectomy and ileostomy due to the steroid-resistant refractory disease, and a restorative proctectomy with ileal pouch-anal anastomosis and proximal neoileostomy was postponed due to active residual rectal inflammation in January 2016. A few months after the neoileostomy, she began to suffer from recurrent episodes of watery diarrhea. She was diagnosed with postcolectomy enteritis and stoma closure acquired a good therapeutic effect. However, her symptoms of diarrhea relapsed in 2019, with different histological features of endoscopic biopsies compared with 2016, which showed apoptotic bodies, a lack of goblet and Paneth cells, and villous blunting. A diagnosis of AIE was established, and the patient’s stool volume decreased dramatically with the treatment of methylprednisolone 60 mg/d for 1 wk and tacrolimus 3 mg/d for 4 d. Meanwhile, her constantly evaluated cholestatic enzymes and high titers of antimitochondrial antibodies indicated the diagnosis of PBC, and treatment with ursodeoxycholic acid (16 mg/kg per day) achieved satisfactory results.
CONCLUSION Some immune-mediated diseases may be promoted by operation due to microbial alterations in UC patients. Continuous follow-up is essential for UC patients with postoperative complications.
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Affiliation(s)
- Qing-Yang Zhou
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei-Xun Zhou
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xi-Yu Sun
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Bin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei-Yang Zheng
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jia-Ming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
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Ulcerative colitis-related postoperative enteritis treated with anti-tumor necrosis factor therapy: two case reports and a literature review. Clin J Gastroenterol 2021; 14:1396-1403. [PMID: 34302278 DOI: 10.1007/s12328-021-01485-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Abstract
Several case reports have described severe postoperative enteritis shortly after total colectomy for ulcerative colitis. The very low incidence of this condition makes diagnosis and treatment difficult, and the appropriate treatment strategy is unclear. We report two cases of enteritis after surgery for ulcerative colitis, which were treated with anti-tumor necrosis factor-α therapy. Case 1 involved a 22-year-old man with symptoms, such as nausea 40 days after total colectomy. Gastrointestinal endoscopy revealed patchy obliteration of the vascular pattern, erosions in the duodenum, and superficial ulcers in the small intestine. His symptoms and endoscopic findings immediately improved upon administration of infliximab; clinical remission lasted 5 years with continuous administration. Case 2 involved a 64-year-old man, who had a large amount of watery diarrhea from ileostomy that increased 5 days after total colectomy; gastrointestinal endoscopy revealed extensive ulcers in the small intestine. Symptoms and endoscopic findings improved with prednisolone, but relapsed with tapering of the corticosteroid. Administration of adalimumab resulted in marked improvement of enteritis. However, the small intestine developed a pinhole stricture, and partial resection of the small intestine was performed. Our experience with two cases indicates that anti-tumor necrosis factor-α therapy may play an important role in ulcerative colitis-related postoperative enteritis.
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Gonella F, Massucco P, Daperno M, Mineccia M, Perotti S, Rocca R, Ferrero A. Ulcerative enteritis. How the extension of ulcerative colitis to small bowel may jeopardize postcolectomy course: a case report and literature review. Eur J Gastroenterol Hepatol 2021; 33:589-594. [PMID: 33657604 DOI: 10.1097/meg.0000000000002112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Intestinal involvement in ulcerative colitis is generally limited to the colon and rectum. We describe a life-threatening case of ulcerative enteritis occurring after colectomy. Other 53 similar cases are reported in the literature. The aim of this narrative review was to focus on ulcerative enteritis characteristics and diagnostic workup. A 25-year-old boy affected by ulcerative colitis underwent a total colectomy in an urgent setting for septic shock. Postoperative course was characterized by elevated ileostomy output, raised up to 10 L/day. Critical clinical conditions required resuscitation therapy. After exclusion of surgical complications, intestinal infections, and histologic specimen revision, the patient underwent endoscopic examination. Ileal biopsies revealed ileal localization of ulcerative colitis. Steroid treatment was finally effective. After literature revision, we classified all cases of ulcerative enteritis in three groups, according to intestinal involvement pattern and timing of clinical manifestation after operation. Out of 54 cases, 18 occurred within 1 month since colectomy (early ileitis), 10 later on (late ileitis) and 26 do not involve ileus (nonileitis). Clinical manifestation is generally severe in the first group and mild and chronic in the others. Differential diagnoses of ulcerative enteritis are represented by infectious, immunological, toxic, and ischemic disorders. Those conditions excluded, ulcerative enteritis can be easily detected by endoscopic biopsies and treated with immunosuppressive agents. Long term surveillance seems important since recurrences are described. In conclusion, clinicians should suspect ulcerative enteritis in all patients with previous colectomy history that develop unexplained gastrointestinal syndromes, in order to avoid therapeutic delay.
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Affiliation(s)
| | | | - Marco Daperno
- Gastroenterology and Endoscopic Unit, Umberto I Mauriziano Hospital, Turin, Italy
| | | | | | - Rodolfo Rocca
- Gastroenterology and Endoscopic Unit, Umberto I Mauriziano Hospital, Turin, Italy
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Kohyama A, Watanabe K, Sugita A, Futami K, Ikeuchi H, Takahashi KI, Suzuki Y, Fukushima K. Ulcerative colitis-related severe enteritis: an infrequent but serious complication after colectomy. J Gastroenterol 2021; 56:240-249. [PMID: 33155079 DOI: 10.1007/s00535-020-01742-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM After colectomy for ulcerative colitis (UC), very severe and sometimes lethal enteritis can develop. However, the clinical features remain uncertain because of the low incidence, diversity of symptoms, and undefined diagnostic criteria. The aim of this study was to define postoperative ulcerative colitis-related severe enteritis (UCRSE) and to investigate its clinical features. METHODS A retrospective multicenter study was performed as a survey of major medical facilities utilizing surgical supplies for inflammatory bowel disease in Japan from 2001 to 2014. UCRSE was defined as a case with massive intestinal bleeding, intestinal perforation, high-output stoma, and/or a requirement for medications, such as steroids and biologics. Patients with gastroduodenal lesions or pouchitis alone were excluded. The incidence, symptoms, involvement of bacteria, cytomegalovirus reactivation, treatment, and prognosis were examined for patients with UCRSE after colectomy. RESULTS Forty-two (0.8%) out of 5284 cases met the criteria for UCRSE. Major symptoms were massive intestinal bleeding (76.2%), which required a median of 3850 (560-18900) mL blood transfusion; high-output stoma (38.1%) with excretion of fluid of 5000 (2000-7800) mL/day; and intestinal perforation (7.1%). Hypovolemic shock (35.7%) and/or disseminated intravascular coagulation (31.0%) developed as serious complications. Tests for cytomegalovirus reactivation were positive in 26.2% of cases. The presence of pathogenic bacteria was confirmed in only 5 cases. Corticosteroids or infliximabs were effective in half of the patients. Thirteen cases (31.0%) were treated surgically and 22 cases (56.4%) required maintenance therapy. The mortality rate was 11.9%. CONCLUSION UCRSE is a rare but serious complication after colectomy and is sometimes life-threatening.
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Affiliation(s)
- Atsushi Kohyama
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kazuhiro Watanabe
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Akira Sugita
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Kitaro Futami
- Department of Surgery, Fukuoka University, Chikushi Hospital, Fukuoka, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Yasuo Suzuki
- Inflammatory Bowel Disease Center, Toho University Sakura Medical Center, Sakura, Japan
| | - Kouhei Fukushima
- Division of Surgical and Molecular Pathophysiology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Laboratory of Gastrointestinal Tract Reconstruction, Tohoku University Graduate School of Biomedical Engineering, Sendai, Japan
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Gastroduodenal Ulcerative Colitis in Association with Ulcerative Pancolitis. Case Rep Gastrointest Med 2021; 2021:6684806. [PMID: 33628535 PMCID: PMC7895600 DOI: 10.1155/2021/6684806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/27/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammatory bowel disease, traditionally regarded as being limited to the colorectum. Although several gastroduodenal lesions have been reported in cases of UC, in general, duodenal lesions in UC are believed to be uncommon and gastric lesions in UC are a rare presentation. In this report, we presented a 66-year-old lady with upper GI presentation with gastroduodenal ulcerative colitis accompanying pancolonic UC.
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α4 β7 Integrin Antagonist Vedolizumab for the Treatment of Refractory Ileitis. Case Rep Gastrointest Med 2019; 2019:2091089. [PMID: 31143480 PMCID: PMC6501135 DOI: 10.1155/2019/2091089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/09/2019] [Indexed: 11/22/2022] Open
Abstract
Background and Aims Ulcerative colitis (UC) is a superficial diffuse inflammation restricted to the colon and rectum. Inflammation within the small bowel may occur several years after a pancolectomy. The pathogenesis is unknown and seems to be different from Crohn's disease or other causes of diseases of the small intestine, but an association with colectomy due to UC is very likely. Methods and Results We describe the case of a patient with a probable diagnosis of pan-UC accompanied by Sjögren's syndrome and partial IgA deficiency, who developed enteritis after a restorative pancolectomy. For induction and maintenance of remission, the patient was successfully treated with mycofenolate mofetil (MMF) and vedolizumab (VDZ). Conclusions We suggest that a previously refractory to standard therapy UC-related enteritis can be treated with combination MMF and VDZ.
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11
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Yang Y, Liu Y, Zheng W, Zhou W, Wu B, Sun X, Chen W, Guo T, Li X, Yang H, Qian J, Li Y. A literature review and case report of severe and refractory post-colectomy enteritis. BMC Gastroenterol 2019; 19:61. [PMID: 31023233 PMCID: PMC6482549 DOI: 10.1186/s12876-019-0974-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 04/02/2019] [Indexed: 01/10/2023] Open
Abstract
Background Ulcerative colitis (UC)-related post-colectomy enteritis is a very rare condition that is characterized by diffuse small-bowel mucosal inflammation following colectomy and could be very dangerous. In previously reported cases, corticosteroid therapy seemed to be the optimal choice for inducing remission; however, the patient studied herein presented with severe diarrhoea and hypovolemic shock and failed to achieve full remission with corticosteroid therapy. Case presentation We describe the case of a patient with severe pan-enteritis presenting with life-threatening diarrhoea complicated with hypovolemic shock and acute kidney injury after colectomy and ileal pouch anal anastomosis (IPAA) for UC; this patient was successfully treated by ileostomy closure after failing to achieve full remission with corticosteroid therapy. Next, we review other cases of post-colectomy enteritis reported in the literature and propose a flow-chart for its diagnosis and initial treatment. Conclusion Post-colectomy enteritis can be dangerous, and the early awareness of this condition plays a vital role. Additionally, in patients who do not respond well to corticosteroid or immunosuppressant therapy, early closure of the ileostomy and re-establishment of the natural faecal stream could be important considerations. Electronic supplementary material The online version of this article (10.1186/s12876-019-0974-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yingyun Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, No. 1 Dongshuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yuan Liu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, No. 1 Dongshuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Weiyang Zheng
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, No. 1 Dongshuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Weixun Zhou
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiyu Sun
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Chen
- Department of Nutrition, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Guo
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, No. 1 Dongshuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Xiaoqing Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, No. 1 Dongshuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Hong Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, No. 1 Dongshuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jiaming Qian
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, No. 1 Dongshuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, No. 1 Dongshuaifuyuan, Dongcheng District, Beijing, 100730, China.
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Abstract
RATIONALE Ulcerative colitis (UC) is a chronic, nonspecific, inflammatory disease of the colon. Colorectal is the main target organ of UC, while other digestive tract involvement is rare. This report describes 2 rare cases of duodenal mucosa lesions in patients with UC after total colectomy. PATIENT CONCERNS In case 1, a patient of 45-year-old with intermittent diarrhea and bloody mucosanguineous feces who was diagnosed as UC, revealed diffuse erosive ulcers in the descending duodenum through gastroscopy after total colectomy. In case 2, a 55-year-old Chinese female with UC, aggravated to colon cancer and received total colectomy. Eighteen months after surgery, the patient was admitted to hospital following upper abdominal pain and acid regurgitation. A gastroscopy found inflammation in the descending part of the duodenum. DIAGNOSIS UC, duodenal mucosa lesions INTERVENTIONS:: In case 1, the patient was treated with oral mesalazine (1 g/tid) and hydrocortisone (0.3 g/d) but symptoms did not improve, and the treatment was changed to oral methylprednisolone (0.6 g/d) and a hydrocortisone enema (0.1 g/late). Finally, the patient underwent a total colectomy and ileostomy. In case 2, the patient was treated with sulfasalazine, mesalazine, and intermittent hormone enemas. A total colectomy and ileostomy were performed with the patient after diagnosed as colon cancer. After surgery, the patient received N1-(2 tetrahydrofuryl)-5-fluorouracil (FT-207), 8 g, 300 mg, and 100 mg oxaliplatin chemotherapy, and biologic therapy. OUTCOMES In case 1, the patient presented with duodenal necrosis and died of septic shock. In case 2, the patient recovered well without recurrence by taking proton pump inhibitor. LESSONS The occurrence of UC related ulcerative gastroduodenal mucosal lesions may be associated with progressing UC or total colitis that does not respond to hormone therapy, leading to requirement of total colectomy.
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Affiliation(s)
| | | | | | - Hai Qin
- Department of Colorectal Surgery
| | - Yang Shi
- Department of Colorectal Surgery
| | | | - Yongjie Zhao
- Department of General Surgery, Tianjin Union Medical Center, Tianjin, China
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13
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Abstract
Autoimmune enteropathy is a rare but severe disorder with significant immune-mediated changes. We present a 54-year-old woman with history of refractory ulcerative colitis status post total colectomy with end ileostomy who presented 1 month after her surgery with high ostomy output of 4 L/d. After a negative workup, ileoscopy with biopsies showed severe chronic active ileitis. Enteroscopy revealed diffuse chronic enteritis concerning for autoimmune enteropathy. She was started on budesonide and intravenous solumedrol, but her ostomy output remained high. She was then started on cyclosporine and later tacrolimus with significant clinical improvement and normalization of ostomy output on tacrolimus.
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14
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Autoimmune Enteropathy in an Ulcerative Colitis Patient. ACG Case Rep J 2018. [DOI: 10.14309/02075970-201805110-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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15
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16
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Okabayashi S, Kobayashi T, Sujino T, Ozaki R, Umeda S, Toyonaga T, Saito E, Nakano M, Tablante MC, Morinaga S, Hibi T. Steroid-refractory extensive enteritis complicated by ulcerative colitis successfully treated with adalimumab. Intest Res 2017; 15:535-539. [PMID: 29142523 PMCID: PMC5683986 DOI: 10.5217/ir.2017.15.4.535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/11/2017] [Accepted: 01/16/2017] [Indexed: 12/22/2022] Open
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.
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Affiliation(s)
- Shinji Okabayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Tomohisa Sujino
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Ryo Ozaki
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Satoko Umeda
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Takahiko Toyonaga
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Eiko Saito
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Masaru Nakano
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Maria Carla Tablante
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Shojiroh Morinaga
- Department of Diagnostic Pathology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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17
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Freeman HJ. Celiac disease: a disorder emerging from antiquity, its evolving classification and risk, and potential new treatment paradigms. Gut Liver 2015; 9:28-37. [PMID: 25547088 PMCID: PMC4282854 DOI: 10.5009/gnl14288] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Celiac disease is a chronic genetically based gluten-sensitive immune-mediated enteropathic process primarily affecting the small intestinal mucosa. The disorder classically presents with diarrhea and weight loss; however, more recently, it has been characterized by subclinical occult or latent disease associated with few or no intestinal symptoms. Diagnosis depends on the detection of typical histopathological biopsy changes followed by a gluten-free diet response. A broad range of clinical disorders may mimic celiac disease, along with a wide range of drugs and other therapeutic agents. Recent and intriguing archeological data, largely from the Gobleki Tepe region of the Fertile Crescent, indicate that celiac disease probably emerged as humans transitioned from hunter-gatherer groups to societies dependent on agriculture to secure a stable food supply. Longitudinal studies performed over several decades have suggested that changes in the prevalence of the disease, even apparent epidemic disease, may be due to superimposed or novel environmental factors that may precipitate its appearance. Recent therapeutic approaches are being explored that may supplement, rather than replace, gluten-free diet therapy and permit more nutritional options for future management.
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Affiliation(s)
- Hugh J Freeman
- Department of Medicine, University of British Columbia, Vancouver, Canada
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18
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Tacrolimus Therapy for Ulcerative Colitis-Associated Post-Colectomy Enteritis. ACG Case Rep J 2014; 2:33-5. [PMID: 26157899 PMCID: PMC4435352 DOI: 10.14309/crj.2014.76] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 07/30/2014] [Indexed: 12/20/2022] Open
Abstract
Ulcerative colitis (UC)-associated pan-enteritis is a newly identified clinical entity that occurs almost exclusively after colectomy. Characterized by diffuse small bowel mucosal inflammation not compatible with Crohn's disease, the optimal treatment modality for this condition is unknown. Tacrolimus is a potent calcineurin inhibitor that has been successfully used in the treatment of UC. We describe a case of severe refractory pan-enteritis after colectomy for UC that was successfully treated with oral tacrolimus after failing intravenous corticosteroid treatment. Tacrolimus may be a safe and effective treatment modality for diffuse enteritis after colectomy in UC patients.
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Clinical features and treatment of ulcerative colitis-related severe gastroduodenitis and enteritis with massive bleeding after colectomy. Int J Colorectal Dis 2014; 29:239-45. [PMID: 24105365 DOI: 10.1007/s00384-013-1779-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2013] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Ulcerative colitis (UC) has been recognised as a systemic immune disorder that is not as restricted as colitis. UC-related gastrointestinal lesions with bleeding can develop soon after colectomy and can progress rapidly. Therefore, we considered the clinical features and treatment of these UC-related lesions. METHODS We reviewed the patient data in our UC surgery database to evaluate its prevalence and features. RESULTS We found 7/1,100 patients with UC-related lesions between January 2000 and April 2013. These lesions developed at a mean of 24 (range 8-480) days after colectomy. Six of the seven patients suffered from gastrointestinal bleeding as an initial symptom that rapidly developed into massive bleeding or perforations. All of the patients were diagnosed with pancolitis; at the time of colectomy, fulminant, severe, moderate, and mild colitis were presented by four, one, one, and one patients, respectively. All patients with enteritis had consecutively developed other infectious complications, including anastomotic leakage, pyoderma gangrenosum, wound infection, and pneumonia. Although patients with bleeding did not respond to treatment with corticosteroids, they responded well to infliximab soon after its administration. Although six of the seven patients showed cytomegalo virus re-activation in blood or pathological examinations, ganciclovir was not effective in its elimination. CONCLUSION Although UC-related lesions with an unknown aetiology can occur after colectomy, immediate examination and treatment are required if gastrointestinal bleeding is found after surgery. Because gastrointestinal bleeding from UC-related lesions can worsen rapidly and may be related to mortality, early potent immunosuppressive therapy should be considered.
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Saito K, Katsuno T, Nakagawa T, Minemura S, Oyamada A, Kanogawa N, Saito M, Yoshihama S, Maruoka D, Matsumura T, Arai M, Tohma T, Miyauchi H, Matsubara H, Yokosuka O. Severe diffuse duodenitis successfully treated with intravenous tacrolimus after colectomy for ulcerative colitis. Intern Med 2014; 53:2477-81. [PMID: 25366006 DOI: 10.2169/internalmedicine.53.1910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
We encountered a rare case of severe diffuse duodenitis associated with ulcerative colitis (UC). A 23-year-old man underwent total proctocolectomy with ileal J-pouch anal anastomosis for UC. He suffered from severe abdominal pain, fever and bloody diarrhea for six months after the surgery. Upper double-balloon enteroscopy disclosed severe diffuse duodenitis, of which the findings were endoscopically and histologically similar to those of colonic lesions of UC. Although the administration of prednisolone was ineffective, treatment with intravenous tacrolimus markedly improved the clinical findings. This is the first report of the successful treatment of severe UC-associated diffuse duodenitis with intravenous tacrolimus.
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Affiliation(s)
- Keiko Saito
- Department of Gastroenterology and Nephrology (K1), Graduate School of Medicine, Chiba University, Japan
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21
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Severe and extensive enteritis following colectomy for ulcerative colitis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 26:866-7. [PMID: 23248782 DOI: 10.1155/2012/415640] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Hoentjen F, Hanauer SB, Hart J, Rubin DT. Long-term treatment of patients with a history of ulcerative colitis who develop gastritis and pan-enteritis after colectomy. J Clin Gastroenterol 2013; 47:52-7. [PMID: 22858512 PMCID: PMC3874322 DOI: 10.1097/mcg.0b013e3182582c1d] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ulcerative colitis (UC) is generally described as a superficial diffuse inflammation restricted to the colon and rectum. However, several case reports have described a distinct and rare type of UC-related pan-enteritis, typically occurring after colectomy. Corticosteroids are effective for induction of remission of this condition, but it is not clear how these patients should be managed long term. GOALS To further describe and define the entity of UC-related pan-enteritis and to investigate the efficacy of azathioprine for maintenance of remission. RESULTS We describe 5 patients with superficial diffuse ulcerative inflammation of the stomach, small bowel, and pouch if present. Four of the 5 patients developed enteritis after colectomy for ulcerative pancolitis. Pathology showed severe mucosal inflammation with infiltration of neutrophils and plasma cells from the stomach to the ileum. Video capsule endoscopy in 1 patient confirmed the presence of mucosal inflammation throughout the small bowel. All patients were started on a standardized treatment with intravenous corticosteroids for induction of remission and azathioprine for maintenance therapy. The conditions of all the patients rapidly improved, and subsequently, 4 patients were in full remission on azathioprine monotherapy, despite failure of this UC therapy before surgery, whereas 1 patient continues to have a steroid-dependent disease. CONCLUSIONS The outcomes of 5 cases of UC-related pan-enteritis as described in this report support a role for azathioprine in remission maintenance. Future research is needed to improve our understanding of this rare but distinct intestinal inflammatory disorder.
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Affiliation(s)
- Frank Hoentjen
- Inflammatory Bowel Disease Center, University of Chicago Medical Center, Chicago, USA,Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stephen B. Hanauer
- Inflammatory Bowel Disease Center, University of Chicago Medical Center, Chicago, USA
| | - John Hart
- Department of Pathology, University of Chicago Medical Center, Chicago, USA
| | - David T. Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medical Center, Chicago, USA
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23
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Lu LS, Ding WX. Surgical treatment of ulcerative colitis. Shijie Huaren Xiaohua Zazhi 2010; 18:3125-3128. [DOI: 10.11569/wcjd.v18.i29.3125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis (UC) is an inflammatory disease of the colon. Medicinal treatment is the standard therapy for UC. However, almost 20%-30% of UC patients fail to respond to medicinal treatment and need to receive surgical treatment. Nowadays, the extensive use of laparoscopic surgery and double stapling technique has greatly decreased the incidence of trauma and complications associated with surgical treatment of UC. Surgical treatment of UC has attracted more and more attention of clinicians.
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24
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Abstract
Involvement of the upper gastrointestinal tract by inflammatory bowel disease was long held to be a feature of Crohn's disease, whereas ulcerative colitis was considered to be limited to the colon. It is now recognized that ulcerative colitis associated inflammation can involve the upper gastrointestinal tract, primarily the stomach. In addition to aphthoid esophageal ulcers in Crohn's disease, eosinophilic esophagitis and so-called lymphocytic esophagitis occur in association with ulcerative colitis and Crohn's disease. Possible immune mechanisms behind these conditions are presented. The differential diagnosis of inflammation in each site is discussed.
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Affiliation(s)
- Neal S Goldstein
- Advanced Diagnostics Laboratory, PLLC, 25241 Grand River Avenue, Redford, MI 483240, USA.
| | - Mitual Amin
- Department of Anatomic Pathology, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA
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25
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Akitake R, Nakase H, Tamaoki M, Ueno S, Mikami S, Chiba T. Modulation of Th1/Th2 balance by infliximab rescues postoperative occurrence of small-intestinal inflammation associated with ulcerative colitis. Dig Dis Sci 2010; 55:1781-4. [PMID: 19672713 DOI: 10.1007/s10620-009-0910-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Accepted: 07/05/2009] [Indexed: 12/24/2022]
Affiliation(s)
- Reiko Akitake
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
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Diffuse enteritis after colectomy for ulcerative colitis: two case reports and review of the literature. Eur J Gastroenterol Hepatol 2009; 21:710-5. [PMID: 19282770 DOI: 10.1097/meg.0b013e32831bc400] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Ulcerative colitis (UC) is an inflammatory disease of the colon. Involvement of the small bowel is limited to backwash ileitis or pouch-related conditions. Here, we report two men with UC who presented with small bowel inflammation and even perforation, within 1 month after subtotal colectomy. Endoscopy showed diffuse enteritis. Histology showed marked apoptosis of epithelial cells in both cases. One patient responded to steroids and the other to a calcineurin inhibitor. Both patients had no evidence of Crohn's disease in the small intestine before this event. Several more cases of small intestinal lesions in patients with well-established UC have been reported. The majority typically presented shortly after colectomy and responded well to steroids. The pathogenesis of this enteritis is unknown, but seems to be distinct from Crohn's disease and may be associated with UC and colectomy.
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27
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Abstract
A new, hypervirulent strain of Clostridium difficile, called NAP1/BI/027, has been implicated in C. difficile outbreaks associated with increased morbidity and mortality since the early 2000s. The epidemic strain is resistant to fluoroquinolones in vitro, which was infrequent prior to 2001. The name of this strain reflects its characteristics, demonstrated by different typing methods: pulsed-field gel electrophoresis (NAP1), restriction endonuclease analysis (BI) and polymerase chain reaction (027). In 2004 and 2005, the US Centers for Disease Control and Prevention (CDC) emphasized that the risk of C. difficile-associated diarrhea (CDAD) is increased, not only by the usual factors, including antibiotic exposure, but also gastrointestinal surgery/manipulation, prolonged length of stay in a healthcare setting, serious underlying illness, immune-compromising conditions, and aging. Patients on proton pump inhibitors (PPIs) have an elevated risk, as do peripartum women and heart transplant recipients. Before 2002, toxic megacolon in C. difficile-associated colitis (CDAC), was rare, but its incidence has increased dramatically. Up to two-thirds of hospitalized patients may be infected with C. difficile. Asymptomatic carriers admitted to healthcare facilities can transmit the organism to other susceptible patients, thereby becoming vectors. Fulminant colitis is reported more frequently during outbreaks of C. difficile infection in patients with inflammatory bowel disease (IBD). C. difficile infection with IBD carries a higher mortality than without underlying IBD. This article reviews the latest information on C. difficile infection, including presentation, vulnerable hosts and choice of antibiotics, alternative therapies, and probiotics and immunotherapy. We review contact precautions for patients with known or suspected C. difficile-associated disease. Healthcare institutions require accurate and rapid diagnosis for early detection of possible outbreaks, to initiate specific therapy and implement effective control measures. A comprehensive C. difficile infection control management rapid response team (RRT) is recommended for each health care facility. A communication network between RRTs is recommended, in coordination with each country’s department of health. Our aim is to convey a comprehensive source of information and to guide healthcare professionals in the difficult decisions that they face when caring for these oftentimes very ill patients.
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