Intest Res  
Steroid-refractory extensive enteritis complicated by ulcerative colitis successfully treated with adalimumab
Shinji Okabayashi1, Taku Kobayashi1, Tomohisa Sujino1, Ryo Ozaki2, Satoko Umeda2, Takahiko Toyonaga2, Eiko Saito1, Masaru Nakano2, Maria Carla Tablante1, Shojiroh Morinaga3, Toshifumi Hibi1
1Center for Advanced IBD Research and Treatment, Departments of 2Gastroenterology and Hepatology and 3Diagnostic Pathology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
Correspondence to: Taku Kobayashi, Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, 5-9-1 Shirokane, Minato-ku, Tokyo 108-8642, Japan. Tel: +81-3-3444-6161, Fax: +81-3-3444-2530, E-mail: kobataku@insti.kitasato-u.ac.jp
Received: November 30, 2016; Revised: January 11, 2017; Accepted: January 16, 2017; Published online: March 7, 2017.
© Korean Association for the Study of Intestinal Diseases. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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.
Keywords: Ulcerative colitis; Enteritis; Inflammatory bowel disease; Capsule endoscopy; Balloon-assisted enteroscopy


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