Long-term ulcerative colitis. Severe outbreak. Diagnostic-therapeutic approach
The patient is a 32-year-old woman with no other history of interest, diagnosed with ulcerative pancolitis 8 years ago. For the last 3 years she has been treated with azathioprine (2.5 mg/kg) due to steroid dependence.
Her clinical symptoms include more frequent bowel movements (6–8/day), all containing blood, with general malaise, weight loss and loss of appetite. The lab tests showed anaemia (haemoglobin [Hb] 9.5 g/dl) and increased C-reactive protein (CRP) (42 mg/l), with the remaining measured parameters within normal range. Due to the clinical deterioration with development of a moderate-severe outbreak in a previously-stable patient, we proposed performing a:
COLONOSCOPY (Video 1)
We observed continuous pancolonic involvement of the mucosa, starting from the beginning of the examination, with oedema, mucosal thickening, friability and the presence of extensive ulcers, some of which were quite deep, and more striking moving towards the right colon. The endoscopic findings are compatible with an ulcerative colitis outbreak with moderate-severe pancolonic endoscopic involvement.
Based on the referenced symptoms and the findings of the endoscopy, we decided to start infliximab treatment at the usual induction dose (5 mg/kg in weeks 0,2 and 6), with early clinical response, continuing with maintenance treatment (5 mg/kg every 8 weeks) in monotherapy for one year.
After one year, the patient was found to be in clinical remission with lab test parameters within normal ranges. As this patient has a disease duration of over 8 years, we decided to perform a repeat endoscopy to evaluate subsequent endoscopic follow-up (dysplasia screening) and to monitor the activity in the mucosa.
REPEAT COLONOSCOPY (Video 2)
The endoscopy showed great improvement compared to the previous examination, with the mucosal lesions practically healed.
In the caecum, we found and biopsied a pseudopolypoid lesion of approximately 1.2 cm. Biopsies were taken from the caecum, ascending and transverse colon, left colon and rectum for histological study.
The histological study of the caecal lesion found low-grade dysplastic foci, with no other dysplastic lesions found in the samples obtained. Due to the diagnosis of an adenoma-like dysplasia-associated mucosal lesion (DAML), with mild dysplastic foci (Fig. 1 and Fig. 2), we decided to perform endoscopic resection of the lesion.
As a single raised lesion with low-grade dysplasia was found to be susceptible to endoscopic resection, with no other mucosal abnormalities, we performed an endoscopic polypectomy of the lesion with loop diathermy, without incident (Video 3).
The tissue was collected for histological assay, which confirmed the previous findings. In dysplastic lesions associated with colitis, it must be ensured that no residual dysplastic mucosal lesions remain around the eschar or in the rest of the mucosa.
After resection we performed a repeat endoscopy with chromoendoscopy and targeted lesions after 6 months, which were negative, so we decided to perform annual follow-up with chromoendoscopy (Video 4).
SUPPORTING SCIENTIFIC UPDATE
• II.1.2.2. Endoscopy in the follow-up of ulcerative colitis
• II.4.1. Endoscopic follow-up of dysplasia in colitis associated with inflammatory bowel disease
• II.4.2. Chromoendoscopy and narrow band imaging in screening and follow-up of dysplasia in inflammatory bowel disease
• III.1. Endoscopic treatment of dysplastic lesions associated with inflammatory bowel disease