Case 7. Long-evolving ulcerative colitis with sustained endoscopic-histological inflammation

 

CORTICOSTEROID DEPENDENCY LOSS OF EFFECT OF AZATHIOPRINE.
MUCOSAL HEALING WITH INFLIXIMAB.
DEVELOPMENT OF A POLYPOID LESION WITH DYSPLASIA.

A 27-year-old patient diagnosed 10 years ago with ulcerative pancolitis. Clinically stable and subjected to maintenance therapy with azathioprine (2.5 mg/kg) for over three years. On occasion of the last controls the patient claimed to feel worse, with an increase in the number of blood-containing stools, associated to asthenia and loss of appetite. The laboratory tests evidenced mild ferropenic anemia and increased C-reactive protein.

 

Figure 1. Colonoscopy: Ulcerative pancolitis. Severe endoscopic disease. Continued involvement with extensive confluent longitudinal ulcers which upon progressing proximally show some depth, edema and mucosal friability.
 

Treatment was started with infliximab, followed by a very good clinical-laboratory test response. Maintenance therapy was continued every 8 weeks. One year later the patient was in clinical remission and subjected to endoscopic monitoring.

 

Figure 2. Colonoscopy: Healing of the mucosa is seen, with disappearance of the previous ulcers. Rectified colon, reaching the cecum at 60 cm. At cecal level a polypoid lesion measuring about 2 cm in size was identified. The lesion was biopsied, and the histological study revealed acute and chronic mucosal inflammation with mild epithelial dysplasia.
 

A prolonged duration of ulcerative colitis increases the possibility of dysplastic lesions and neoplasms associated to the disease. Endoscopic disease, with sustained histological inflammation, a short and rectified colon, and pseudo-polypoid lesions or strictures increase the risk of developing lesions of this kind.

 

Figure 3. Colonoscopy: Endoscopic resection and posterior endoscopic monitoring is the therapeutic option currently recommended for polypoid lesions with mild dysplasia that are amenable to complete resection.

 
 

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